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EPSDT STATUS 

A REVIEW OF EIGHT STATES 



SRS-74-63 
DECEMBER 1974 



REPORTS 

RJ 

102 

E6788 

1974 




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B0K0N0N SYSTEMS, INC. ^ ^ ^ 

2000 P STREET, N.W. • SUITE 612 • WASHINGTON, D.C. 20036 • 202 223-2558 



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EPSDT STATUS 

A REVIEW OF EIGHT STATES 



SRS-74-63 
DECEMBER 1974 



B0K0N0N SYSTEMS, INC. 

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2000 P STREET, N.W. • SUITE 612 • WASHINGTON, D.C. 20036 • 202 223 2558 



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EPSDT STATUS 

A REVIEW OF EIGHT STATES 



PURPOSE: AS PART OF AN EFFORT DESIGNED TO DEVELOP A MODEL FOR 
EVALUATION OF EPSDT, EIGHT STATES WERE VISITED TO DETERMINE 
PRESENT PROGRAM STATUS. IN PARTICULAR THE OBJECTIVES OF THESE 
STATE VISITS WERE: 

- TO DESCRIBE INPLACE EPSDT EFFORTS 

- TO DETERMINE WHAT DATA ARE BEING RECORDED 
AND STORED 

- TO DETERMINE WHAT USES ARE BEING MADE OF 
THIS DATA FOR MONITORING, EVALUATION AND 
PLANNING 

DATA WAS ANALYZED AND TABLED IN THE FOLLOWING WAYS: 

- STATE INFORMATION FLOW CHARTS 

A DESCRIPTION OF ACTIVITIES AND DATA 
FILES INPLACE TO SUPPORT THOSE ACTIVITIES. 

- STATE COMPONENT MATRIX 

A LISTING OF PROGRAM COMPONENTS BY STATE. 

- STATE DATA FILE MATRIX 

A LISTING OF DATA FILES BY STATE. 
ACTIVITIES EVIDENCED IN THE STATES WERE ALSO DESCRIBED IN 
NARRATIVE FORM. 



IT WAS FOUND THAT STATES WERE PURSUING EFFORTS TO CARRY OUT 
EPSDT REQUIREMENTS AND IN DOING SO HAD DEVELOPED SOPHISTICATED 
DATA FILES. HOWEVER, DUE TO THE PRESSURE TO IMPLEMENT EPSDT, 
VERY LITTLE ATTENTION IS BEING PAID TO THE USE OF THIS DATA 
FOR MONITORING, EVALUATION OR PLANNING. 

THIS REPORT WILL SERVE AS THE FOCUS FOR THE DEVELOPMENT OF AN 
EVALUATION MODEL BASED ON A CONCEPT OF DATA CLASSIFICATION 
WHICH WILL PERMIT PRESENT STATE DATA FILES TO BE ACCESSED FOR 
EVALUATIVE PURPOSES. 




SYSTEMS 



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TABLE OF CONTENTS 



SUMMARY 
BACKGROUND 

DATA COLLECTION PROCEDURES 

3.1 QUESTIONNAIRES 

3.2 FIELD VISITS 

SITE STATUS 

4.1 STATE SYSTEM INFORMATION FLOW CHARTS 
FLORIDA 

ILLINOIS 
LOUISIANA 
NEW ORLEANS 
OKLAHOMA 
SOUTH CAROLINA 
WASHINGTON 

4.2 DESCRIPTION OF STATE EPSDT STATUS 
4,2.1 ADMINISTRATION 



EPSDT ORGANIZATIONAL STRUCTURES 
OBJECTIVES AND MANAGEMENT PLANNING 
INFORMATION SYSTEMS 
SUMMARY 




FINANCING 


64 


MEDICAID DOLLAR 


68 


SUMMARY 


69 


PROVIDER AGREEMENTS 


70 


SCREENING 


70 


DIAGNOSIS AND TREATMENT 


71 


VENDOR IDENTIFICATION NUMBERS 


72 


SUMMARY 


72 


CLIENT ENROLLMENT 


73 


ELIGIBILITY 


73 


OUTREACH 


75 


SCHEDULING 


77 


NO-SHOWS 


77 


PERIODICITY 


78 


SUPPORT SERVICES 


79 


SCREENING 


79 


PROVIDERS 


80 


SCREENING PACKAGES 


81 


USE OF OTHER HEALTH PROGRAMS 


82 


DATA FILES 


83 


EVALUATION 


84 


DIAGNOSIS AND TREATMENT 


85 


DIAGNOSIS AND TREATMENT INTERFACE 


85 



BOKONON 




PROVIDERS 


87 


EVALUATION 


87 


DATA FILES 


89 


CASE MANAGEMENT 


90 


ENROLLMENT 


91 


SCREENING - DIAGNOSIS & TREATMENT LINKAGE 


92 


TRACKING 


93 


PERIODICITY 


94 


SUMMARY 


94 



APPENDICES 

A, STATE AND LOCAL QUESTIONNAIRES 

R. STATE DATA FILE MATRIX 

C, STATE EPSDT COMPONENT MATRIX 

D. STATE FORMS ON FILE 



BOKONON A IT> SYSTEMS 



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1,0 SUMMARY 



To provide the poor and medically needy with access to health care and 
thereby improve their health status, Federal programs provide services 
(Title V) or financing (Title XVIII and XIX). Early Periodic Screening, 
Diagnosis and Treatment, mandated under 1968 Amendments to Title XIX, is 
unique insofar as it is a financing program whose legislation mandates 
direct services to eligible pediatric populations. 

The difficulties inherent in implementing such a program are further com- 
pounded by the state option in Title XIX which permits states to determine 
the extent of their participation. The result is that EPSDT plans are 
packages of benefits and restrictions tailored to the objectives of indivi- 
dual states. Accordingly, what has been obtained is state by state EPSDT 
development accompanied by unique data collection and storage procedures. 

The wide range of EPSDT data systems constitutes a difficult problem for 
planning and policy making since it makes comparison of different programs 
difficult if not impossible. The development of an evaluation model which 
would require precisely the same data collected within each state would 
create an incredible burden both in time and cost. Furthermore, the success 
of such efforts has been limited primarily because such programs are typi- 
cally developed at the Federal level with Federal requirements in mind and 
frequently neglect the needs of the local project. This serves to limit 
the value of evaluation insofar as the local project, not seeing data 




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collection in terms of their own requirements frequently provide inadequate 
and inappropriate data. 

As a solution to these problems, Bokonon Systems has suggested the develop- 
ment of an evaluation model based on the notion of a data classification 
system. Data describing similar events within the states would be ordered 
through appropriate analytical packages into a common output necessary for 
Federal requirements, while concurrently meeting the needs of local and 
state levels. 

To determine the adequacy of this approach, the data presently being 
collected for use at the Federal level was examined. This data was found 
to be fragmentary and inappropriate for evaluative purposes. Accordingly, 
visits to eight states were carried out in an effort to describe the pre- 
sent EPSDT status. The objectives of this effort were to: 

- determine what activities are taking place at the state and local 



- ascertain what data is being recorded and stored 

- determine how data stored is being used for program monitoring, 
evaluation and planning. 



Visits to eight states were carried out and data was collected and tabled 

in the following ways: 

State System Information Flow Charts: these charts present for each 
state the structure of discrete events in the EPSDT cycle and 
the data flows that are derived from them. 



levels 




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State Data Files Matrix : a listing of EPSDT relevant data files 
on a state by state basis. 

State EPSDT Component Matrix : this matrix describes administrative 
structures on a state by state basis. 

In addition, a narrative description of the findings in all states was pre- 
pared and organized into seven descriptive categories that reflect EPSDT 
concerns. It should be noted that specific state information was submerged 
in these descriptions to maintain confidentiality of information offered by 
state personnel. Following are brief summaries of findings by category: 

ADMINISTRATION 

A wide range of administrative structures were found ranging from distinct 
programmatic units to add-on responsibilities to pre-existing organizational 
structures. 

In general, EPSDT efforts could be described as a screening program with 
diagnosis and treatment services offered under normal Title XIX rules 
(ES-DT) or by a full range program (EPSDT) in which cohesive and organized 
service delivery was in the process of being implemented. 

It is interesting to note that the data files reflect this division. In 
those states where EPSDT is the primary thrust, a unified data system which 
may permit tracking and queing of clients was in operation. For those 
states where early screening was the primary concern, it was typically 




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found that two or more sets of files existed (i.e., screening, diagnosis 
and treatment and in some cases additional payment files where fiscal 
agents were functioning). 

With a single exception, (one state line-itemed all EPSDT functions by 
personnel) it was difficult to ascertain how many administrative personnel 
were employed for EPSDT. In most cases, EPSDT functions were obtained by 
adding responsibilities to existing staff. 

Objectives of the states visited clustered about two concerns: compliance 
or refinement. For the former the objectives specified were those neces- 
sary to meet basic Federal requirements and assure compliance. These 
states typically were in early stages of implementation and could be 
described as "early screening" states. Those states where refinement 
objectives were articulated had passed beyond concerns of initial in- 
putting of children into screening and were concerned with improving 
program effectiveness and efficiency. 

The objective receiving most mention was "to improve record keeping and 
statistics". This suggests that efforts are being directed to the prob- 
lems of monitoring, evaluating and planning as initial struggles in 
implementing EPSDT are surmounted. 

Finally, while states indicated that funds were not a problem, it was 




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clear that the state budget office was a critical factor in the level of 
EPSDT functions. In all states the Governor had specified EPSDT as a high 
priority item and budget offices saw that sufficient funding was available. 

FINANCING 

The costs of EPSDT with the exception of screening are difficult to deter- 
mine. Administrative costs were frequently submerged in other budgets 
making them impossible to assess. The biggest difficulty was in estimating 
diagnosis and treatment costs because of the lack of integration of 
screening, and diagnosis and treatment files. 

The costs for screening ranged from $8.00 to $27.00 and for re-screening 
from $6.50 to $22.50. In no case did a state indicate difficulty in obtain- 
ing appropriations for state's EPSDT share. Finally, it should be noted 
that the use of Medicaid as a first health dollar was rarely the rule. 
This has increased the difficulty of integrating the other Federally 
financed health programs servicing children into the EPSDT structure. 

PROVIDER AGREEMENTS 

States used a number of vendor mixes to provide EPSDT. They ranged from 
public health clinics to solo providers. In general, selection of service 
for screening reflected the states past history in health care so one 
found that states with strong public health programs typically used public 
health clinics as screening providers. In other states, both screening, 
and diagnosis and treatment were provided by solo practitioners. 




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All states indicated difficulty in providing services to rural areas and a 
general paucity of dental providers. States which required enrollment of 
vendors in EPSDT typically needed strong recruitment efforts on the part of 
EPSDT personnel. These programs frequently used financial incentives which 
took two forms: slightly higher flat rates for screening, and prompt 
payment of EPSDT generated billings. 

While the financial incentives did not seem to have major effects, many 
states felt that as economic conditions worsened, rapid payments of EPSDT 
billings which provide vendors with a timely cash flow would lead to 
increased participation. This, however, may prove to be a problem insofar 
as increased services to EPSDT eligibles may result in changes in utiliza- 
tion patterns in other populations. 

CLIENT ENROLLMENT 

While eligible populations are clearly defined in the state Medicaid plans, 
the problem of locating eligible children in need of EPSDT is complex. In 
particular, medically needy children are a problem. In addition, targeting 
specific eligible sub-populations constitutes another problem. Many child- 
ren are receiving services under various programs (e.g. Title V, public 
health, Federal categorical programs and private providers). Penetrating 
this group constitutes a problem insofar as they perceive they are already 
receiving services. 




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In addition, expanded efforts toward all children without selectivity appears 
to result in large numbers of no-shows which increase costs of services and 
may suggest that the state is doing poorer than it is. 

While written mailer and media spots were used in all states most attempted 
to insure direct caseworker contact in recruitment of eligibles. Support 
services did not appear to be a problem with a variety of methods being used 
to provide such services as transportation and day care. 

SCREENING 

The primary EPSDT thrust for the present is directed toward screening. This 
is because of recent Federal and legal pressures. Four states were found 
to use public health clinics for medical screening, while one state relies 
almost entirely on solo providers. The others (three) use combinations. 

One state uses public health dentists and six use private dentists for 
screening. One state does not dental screen and instead refers all 
children for treatment. To overcome problems with provider participation in 
rural areas, one state initiated the use of mobile units for both medical 
and dental screening. 

In terms of the integration with other health programs, a variety of diffi- 
culties were found. School programs were typically not used as they are 
not able to be reimbursed by Title XIX funds, monies they need to improve 



BOKONON^Hf SYSTEMS 



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their functions to meet EPSDT requirements. While some programs funded by 
Title V were heavily involved in EPSDT, others were not. Part of the diffi- 
culty resulted from more general coverage offered by Title V projects 
necessitating special data systems to identify EPSDT eligibles. On-going 
preventive programs such as PKU, vision and hearing screening and immuniza- 
tion were found to have been easily incorporated in EPSDT. Systems were 
found to be of high quality primarily because they were developed concurrently 
with and not as add-ons to other programs. 

Aside from utilization review procedures, the evaluation of screening was 
non-existent. This reflects two problems: the state of the art in deter- 
mining medical service quality, and the lack of time and personnel available 
to carry out such efforts. 

DIAGNOSIS AND TREATMENT 

The intent of EPSDT legislation is manifested when screening identifies 
health problems which are in turn confirmed through diagnosis and subsequently 
receive treatment. The impact of the program requires that one shows that 
early detection of morbidity (for which there is treatment) and treatment 
lead to decreases in long term debilitating illnesses. 

While EPSDT has not been in existance long enough to examine its impact 
the question of whether or not one can determine if the legislative mandate 
is being met is more difficult than would be expected. 




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The primary problem lies in the fact that most states have concentrated on 
in-putting children into screening with the expectation that normal Title XIX 
procedures could provide diagnosis and treatment. Whether this was occurring 
is difficult to determine since most states visited had separate diagnosis 
and treatment data files making it difficult to determine who was receiving 
EPSDT. The problem was further compounded by children who received treat- 
ment during screening for which no bill or report was prepared. The present 
approach is to attempt to match positive screening profiles with diagnosis 
and treatment payment claims. This method is filled with pitfalls: some 
public and private providers are far behind in billings, and some billing 
forms were found not to be specific enought to discriminate episodic encoun- 
ters from a referral. 

The quality of diagnosis and treatment data files varies widely, the most 
prevalent problem being continuity between screening diagnosis and treatment. 
However, a far more serious problem is that resulting from the controversy 
surrounding the use of procedure codes. One state reported that despite 
having Medical Society approval for a code they used, over 70% of treatment 
billings were listed outside the codes as "other". 

Evaluation typically consisted of utilization review procedures although 
one state maintained a mobile dental van which checked quality as well as 
fraud by re-examining children for whom bills have been submitted. No 




state appeared to have long range focus on the use of diagnosis and treatment 
for evaluation nor was any state found to be considering the relationship 
of treatment to outcome as a possible measure of the impact of EPSDT. 



CASE MANAGEMENT 

It appeared from our visits that case management was the most critical 
determinant of the level of success of EPSDT efforts. Strong and aggressive 
case management seems to be able to overcome structural limitations of the 

program. The major problem caseworkers have is the lack of organized file 
systems which would permit them to track clients' status without requiring 
considerable effort on their part to assure continuity through screening, 
diagnosis and treatment. 

In general it can be concluded that the states were moving towards full 
implementation of EPSDT and in doing so had developed sophisticated data 
systems. The biggest problem at present is that immediate concerns have 
left very little time for consideration of uses of the data for monitoring, 
evaluation and planning. 

It is expected that this effort will serve as in-put for the next stage of 
the development of the evaluation model. This next stage, which awaits 
specification of Federal evaluation requirements, will see the use of the 
information collected at the state organized into a data classification 
system. It is intended that the model will demonstrate its usefulness at 
the local level as well as meeting state and Federal evaluation needs. 




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2.0 BACKGROUND 



Federal health programs have evolved along two basic strategies: Cat- 
egorical programs which stress service delivery exemplified by programs 
mandated under Title V of the Social Security Act; and financing programs 
such as Medicare (Title XVIII) and Medicaid (Title XIX). The goal of 
both approaches is the same, namely to provide the poor and medically 
needy with access to health care and thereby improve the health status 
of these populations. 

The former (e.g., Title V programs) provides direct services through 
categorical delivery mechanisms, which increase the availability of 
health services to specific target populations. The latter programs 
(e.g., Title XVIII and XIX) function to eliminate the financial barriers 
which prevent the poor from utilizing available medical services. 

EPSDT, mandated under the 1967 Amendments to Title XIX, is unique in- 
sofar as it is a financing program whose legislation specifies the pro- 
vision of direct services to target populations. The ambiguity result- 
ant from this mix is further compounded by the state option inherent in 
Title XIX which permits the states to determine the extent of their par- 
ticipation in these financing programs. The result is that EPSDT plans 
like State Medicaid Plans, which they are part of, are packages of bene- 
fits and restrictions tailored to the structure, philosophy and ob- 
jectives of individual states. These range from minimally mandated 




services necessary for legislative compliance to the initiation of a pro- 
gram of comprehensive health care to children. 

Implementation of EPSDT has been slow and uneven. The difficulty is a 
function of numerous problems. Despite the fact that legislation was en- 
abled in 1967, it was not until 1972 that the Federal government issued 
regulations and guidelines which were followed by a strong Federal thrust 
for program implementation. Concurrently, many states were faced with 
legal suits resulting in judgements requiring "full" and "rapid" imple- 
mentation. 

This late start under the dual pressures of Federal compliance and legal 
mandates appears to have resulted in the bulk of state efforts being di- 
rected in a hurry-up fashion to locating and funneling children through 
screening to the detriment of an organized, comprehensive EPSDT program. 
This seems to be born out by the nature of available information from 
which to describe various state efforts. What information is available 
appears fragmentary and inconsistent serving to frustrate planning, policy 
making and coordination among the numerous agencies involved in EPSDT at 
all levels of responsibility and operation (i.e., local, state, Federal). 

The problem of understanding the program on the basis of available infor- 
mation is made more complex by the nature of Title XIX legislation. Since 
states are allowed program options and accordingly may provide different 




ranges of services to different target populations, it may be expected 
that the information systems by which states operate would be different 
from state to state. 

The wide range of data systems constitutes a difficult problem for plan- 
ning and policy making, since it makes comparison between programs dif- 
ficult if not impossible. Clearly, the present state of EPSDT contra- 
indicates the traditional evaluation methodology used at the Federal 
level which requires uniform data specifications and collection. 

Parenthetically, it should be noted that even in programs where Federal 
regulations require the collection of uniform data, evaluation results 
have typically been poor and inappropriate. The reasons for this are 
many. Most important, however, is the recognition that uniformly imposed 
information and evaluation systems typically neglect the needs of the 
local implementer who in the final analysis is the responsible agent for 
data collection. Not understanding data collection requirements in terms 
of their own self interest, limited attention is directed to such efforts. 
The result is fragmentary, inaccurate and unreliable data leading to weak 
evaluation. 

In response to these problems, Bokonon Systems has proposed a solution. 
Given the fact that states have initiated EPSDT within different org- 
anizational structures and through different interpretations, a simple 




fact remains: regardless of the nature of EPSDT implementation early and 
periodic screening , di agnosis and treatment must be delivered to the eligibl 
population at a minimal level in each state. Accordingly, there should 
be substantive commonality among the states with respect to what they 
are doing which probably offsets the weighty differences which exist. 

This position gave rise to the notion of the development of a data class- 
ification system which could be used to evaluate a wide range of EPSDT 
efforts. By "classification system" we mean the ordering of data describ- 
ing similar events collected at different states into categories by func- 
tional activities. Such a system would be based on the determination of 
data various states are presently collecting and the organization of this 
data through analyses packages into a common output necessary for Federal 
requi rements . 

To determine the adequacy of this approach, two initial efforts were 
proposed: 

1. Assessment of data presently collected at the 
Federal level. 

2. Site visits to estimate what exists within the 
states . 

In a preliminary report *, data from MSA files were examined and re- 
organized to determine what was known about a limited number of states. 




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Subsequently, eight states were selected for site visits. These states 
the order visited were: 

II linois 

South Carolina 

Flori da 

Washington 

Texas 

Louisiana (New Orleans) ** 

Oklahoma 

New York 

The data collected during these site visits were analyzed and serve as 
the basis for this report. 



Eight states were visited to determine present status of EPSDT informa- 
tion. In particular, state and local personnel were interviewed to: 



DATA COLLECTION PROCEDURES 





determine what activities are taking place at 
state and local levels 

ascertain what data is being recorded and stor- 
ed 

determine how data stored is being used for 
purposes of program monitoring and evaluation. 

At each state, relevant personnel contacted were interveiwed utilizing 

an informal questionnaire. 

3,1 QUESTIONNAIRES 



Review of the MSA data suggested concerns under which program elements 
could be categorized. These were: 



Administration: 



Financing: 



Provider 
Agreements : 



Enrollment: 



Screening: 



Organization of EPSDT bureaucracy 
Policy, planning and objectives 
Information systems 

Costs of EPSDT 

Availabilities by category of ex- 
penditure 

Medicaid regarding other health 
dollars 

Projected direct costs 



Range of enrollment procedures 
Screening and Diagnosis and Treatment 
providers 
Fee schedules 

Means of targeting eligible subpopulations 
Outreach methods and scheduling 
No shows and periodicity 
Determining penetration rate 

Types of providers 

Interaction with other programs 

Types of screening packages 

Records 

Referrals 



' II 1 SYSTEMS 

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B0K0N0N 



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Diagnosis & 
Treatment: 



Types of providers 
Interaction with other programs 
Linkage to screening outcomes 
Fol low-up 

False negatives, false positives 
Records 



Case Management: Responsible agencies 



Peri odi ci ty 

Diagnosis and treatment follow-up 
Records 



To facilitate the interviews, informal questionnaires were prepared in 
which questions relating to EPSDT were organized according to the pre- 
ceeding categories. A separate although similar questionnaire was pre- 
pared for state and local project interviews. These questionnaires ap- 
pear in Appendix A. 

The questionnaires were constructed in such a way as to serve as reference 
questions when available data or oral review of present EPSDT efforts by 
interviewees was insufficient. During the course of the interviews the 
order of questions was changed to reflect the concerns of particular 
states and/or local projects. 

3,2 FIELD VISITS 

A site visit schedule was prepared and contact with Regional Offices was 
initiated. Some changes in scheduling were required insofar as the time 
planned for our visits coincided with the State Compliance Review. 




Before visiting a state, the team assembled in the Regional Office and 
reviewed the interview schedule to determine which question areas it 
would be most beneficial to focus upon. At the same time, Regional Staff 
were queried in an effort to assess their information needs for evalua- 
tion purposes. 

The team consisted of a health specialist and two system specialists who 
after an initial review of state EPSDT efforts met with state personnel 
in their respective specialities. This was done to minimize the amount 
of time at each state and to insure that our presence did not cause major 
disruptions in state operations. 

It is important to note that the wide ranae of state personnel interviewed 

share common attitudes with respect to EPSDT, namely, a stronq dedica- 
tion to ensuring the success of EPSDT. In addition, we were gratified 
by the response of personnel at states, who, despite short notice 
were able to put together appropriate documentation and to provide us 
with detailed descriptions of their programs, necessary to the success 
of this effort. 

One final note, while we expected to spend considerable time at local 
sites, we discovered a remarkable degree of centralization within 
states and for the most part it was not required that we actually go to 
local sites. In cases where it was important, local personnel were made 




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available at the State Offices. However, in particular, site visits were 
made to New Orleans and New York City to meet with the local project 
director and review program operations. 

4.0 SITE STATUS 

The site visit effort was initiated to determine the extent of state 
information and evaluation efforts and to assess whether or not the in- 
formation systems in place could support the concept of using a data 
classification system to meet the evaluation needs at local, state, 
and Federal levels. In particular, the objectives of the state site 
visits were: 

To describe in place EPSDT efforts 

To determine what data are being recorded 

To determine what uses are being made of this data 

During the course of the site visitations, state EPSDT efforts were re- 
viewed and documentation to support information systems and uses of 
information were requested and received. The information gathered at 
the states was then organized so that we could determine the extent of 
information systems available for EPSDT. The data were then detailed in a 
systems flow chart for each state. 

Subsequently, all information collected was organized into seven afore- 
mentioned categories which describe program operations*. Data from states 
*" 

These categories are detailed in PRELIMINARY ANALYSIS OF EPSDT STATUS. 




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was used to describe various phenomena within each category. In addition, 
the barriers to effective functioning vis-a-vis these categories are also 
discussed. 

The following sections present state system flow charts and descriptions 
of EPSDT functions within the eight categories. 

L \,l STATE SYSTEM INFORMATION FLOW CHARTS 

Data gathered at the states which describe the information systems were 
reviewed and reorganized to integrate two critical factors of EPSDT func- 
tions. These are: the structure of discreet events in the EPSDT cycle; 
and the data flows that derive from the events. 

Six states and one local project have been charted. Two states, Texas 
and New York, do not appear. In the case of Texas we are awaiting documen- 
tation to insure completeness and accuracy.* 

In the case of New York State, no chart. has been prepared since the state 



* Our visit to Texas coincided with a trip out of town 
by the State Medicaid n irector whose approval is requir- 
ed before any documentation may leave the State Office. 
State personnel were extremely helpful and much infor- 
mation was gathered including identification of specific 
documentation required for our report. A request for 
this documentation has since been forwarded to the State 
Medicaid Director and we are presently awaiting a res- 



ponse . 




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functions in a supervisory role with Medicaid and EPSDT administration 
being a local option. What this means is that New York State really con- 
sists of 58 separate jurisdictions each of which files its own plan. Par- 
enthetically, it should be noted that the wide range of efforts within New 
York State most probably represents a microcosmic view of EPSDT efforts 
across the nation. 

In addition, it should be noted that New York State is presently attempt- 
ing to implement a Child Health Assurance Program (CHAP). This program 
further extends the parallel between the Federal Government/states and 
New York/counties as CHAP establishes guidelines and mandates county 
plans and objectives. In any event, the complexity of New York State 
coupled with the present state of flux of the program makes charting their 
efforts of no present value. 

Each flow chart is preceded by a brief narrative description of the state's 
EPSDT structure. The organizational structure and inter-relationship be- 
tween various state agencies are then pictured in a graphic presentation. 
Subsequently, information describing EPSDT functions appear. Each function 
is described in terms of responsibility and the file generated by the 
requirement procedures. 

Following is a brief definition of the EPSDT functions: 
EPSDT INITIATION, PLANNING AND POLICY 




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Describes general divisions of responsibility between 
state agencies and subcontractors. 

ELIGIBILITY DETERMINATION AND IDENTIFICATION 

Describes responsibility and method of eligibility 
determination, assignment of identification number 
and eligibility fi les. 

PROVIDER RECRUITMENT 

Describes responsibility and arrangements for provider 
recruitment for screening, diagnosis and treatment and 
dental services. Also, provides identification code, files 
and formal agreements or contracts. 

SCREENING, NOTIFICATION AND SCHEDULING 

Identifies responsibility for notifying and scheduling for 
screening. Includes methods and files. 

NO-SHOWS AND PERIODICITY 

Specifies responsibility for checking no-shows and re- 
scheduling. Identifies files and methods. 

SUPPORT SERVICES 

Identifies types and responsibility for social services 
delivery such as transportation and day care. 

FAMILY CASE HISTORY 

Describes collection and storage of case history, method 
for updating and identifies who can access information. 

SCREENING REIMBURSEMENT 

Specifies who bills whom, fee schedule, storage and 
eligibility checks. 

SCREENING EVALUATION AND UTILIZATION REVIEW 

Who is responsible for evaluation and utilization 
review and how is it performed. 



BOKONON 




SYSTEMS 



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FLORIDA 



EPSDT RESPONSIBILITY 



The Department of Health and Rehabilitation Services, the social ser- 
vices umbrella agency for Florida has allocated EPSDT responsibili- 
ties between the Division of Family Services (the Title XIX agency) 
and the Division of Health. 

The Health Office screens through county health departments. Per 
capita flat rate reimbursement is under authority of the Bureau of 
Medical Servi ces/DFS. The Bureau is responsible for the overall sur- 
veillance and administration of EPSDT. 




FLORIDA 



ORGANIZATION 



DEPARTMENT OF HEALTH AND 
REHABILITATION SERVICES 
(HRS) 



r 



TITLE XIX AGENCY 
DIV. OF FAMILY SERVICES 
(DFS) 




3sZP§ r ki n 9 SuJ>gontzsict_' 




MEDICAL SERVICES BUREAU 
(CLAIMS PROCESSING 
SECTION) 



SERVICE WORKER 



CHILD HEALTH SECTION 



COUNTY HEALTH 
(SCREENING) 



INFORMATION FLOW 



STRUCTURE 



FILE SETS 



EPSDT INITIATION, PLANNING AND POLICY 

BY AGREEMENT BETWEEN DFS AND DH SCREENINGS WILL BE ACCOM- 
PLISHED BY COUNTY HEALTH DEPARTMENTS. 

THE BUREAU OF MEDICAL SERVICES IS RESPONSIBLE FOR THE 
OVERALL SURVEILLANCE AND ADMINISTRATION OF EPSDT. 



AT PRESENT THE DEPARTMENT OF HRS AND THE DEPARTMENT OF 
EDUCATION ARE WORKING TOWARDS A COMPREHENSIVE SCHOOL 
HEALTH SERVICE PLAN. 



EVERY SIX MONTHS DFS AND DH R 
BURSEMENT RATE. (AT 
DEPARTMENT AND $8.50 



NEGOTIATE SCREENING REIM" 
10.00 - 1.50 TO STATE HEALTH 



PRESENT 

TO COUNTY HEALTH DEPARTMENT). 



ELIGIBILITY DETERMINATION AND ID NUMBER 

ALL MEDICAID AFDC, FOSTER CARE AND SSI UNDER AGE TWENTY-ONE. EVERY SIX MONTHS DFS PREPARES AN UPDATED ELIGIBILITY TAPE. 

MONTHLY THEY PRINT-OUT AN ELIGIBILITY LIST BY COUNTIES. 
RESPONSIBILITY OF DFS. ALSO SEND EPSDT INFORMATION EVERY SIX MONTHS. 



PROVIDER RECRUITMENT 

SCREENING: COUNTY HEALTH DEPARTMENT 

DIAGNOSIS AND TREATMENT: RESPONSIBILITY OF MSB TO PROVIDE 
COUNTY HEALTH DEPARTMENTS WITH A LIST OF MEDICAID PROVIDERS. 
DIAGNOSIS AND TREATMENT VENDORS MUST APPLY TO STATE BOARD 
OF HEALTH. 



STRUCTURE 



FILE SETS 



NOTIFICATION AND SCHEDULING FOR SCREENING 

EITHER DFS SERVICE WORKER OR THE COUNTY DEPARTMENT OF THE DFS ELIGIBILITY TAPE IS USED BY MEDICAL SERVICE BUREAU 

HEALTH CAN SET UP AN APPOINTMENT BY USING THE MONTHLY TO SET UP: 

ELIGIBILITY REPORT ISSUED BY DFS . ,. 

1) INDIVIDUAL SERVICE FILE • 

2) TO CHECK IF TRANSACTION NUMBER CAN BE ISSUED. 



NO SHOWS AND PERIODICITY 

RESPONSIBILITY OF DFS SERVICE WORKER OR COUNTY HEALTH 
DEPARTMENT TO NOTIFY SERVICE WORKER OF A NO SHOW. 



SUPPORTIVE SERVICES 

PROVIDING TRANSPORTATION OR DAY CARE IS RESPONSIBILITY OF 
DFS SERVICE WORKER. 

- OR - 

DH WILL SET UF A SCREENING TEAM TO GO TO RURAL AREAS. 



FAMILY CASE HISTORY 

DFS OBTAINS INFORMATION AT ELIGIBILITY DETERMINATION. HARDCOPY RETAINED BY DFS AT STATE LEVEL. 



REIMBURSEMENTS FOR SCREENING 

1) NO SET SCREENING FORM FOR RECORDING THE EXAMINATION. 



2) MONTHLY MEDICAID SCREENING REPORT FORM FILLED OUT BY 
HEALTH CLINIC. (JUST TOTALS). 

3) AFTER A SCREENING THE PROVIDER OBTAINS FROM DFS A 
TRANSACTION NUMBER FOR EACH CHILD. WITHIN A WEEK DFS 
SENDS A SCREENING BILLING DOCUMENT WICH IS FILLED IN 
BY THE HEALTH CLINICS AND SENT TO MSB. 



SCREENING EVALUATION AND UR 

CHILD HEALTH INVESTIGATES BY SITE VISITS AND QUESTION- 
NAIRES. 



1) HARDCOPY KEPT BY HEALTH CLINIC. 



2) HARDCOPY KEPT BY. DFS. 



3) MSB UPDATES TRANSACTION NUMBER TAPE AND GENERATES A 
SCREENING BILLING DOCUMENT. THE INDIVIDUAL SERVICE 
FILE IS UPDATED WITH SCREENING PERFORMED AND PROCEDURE 
CODES FOR REFERRALS, 



MEDICAL CASE HISTORY 

IF PARENT IS PRESENT AT SCREENING HISTORY INFORMATION 
SHOULD BE REQUESTED BY COUNTY HEALTH DEPARTMENT. 



COUNTY HEALTH CLINICS MAY KEEP HARDCOPY OF THEIR SCREENING 
FORM. 

MSB KEEPS HARDCOPY OF SCREENING BILLING DOCUMENT AND 
DIAGNOSIS AND TREATMENT BILLS. 

DOCTOR OR DENTIST SHOULD KEEP CASE HISTORY. 



REFERRAL FOR DIAGNOSIS AND TREATMENT 

APPOINTMENTS MADE EITHER BY COUNTY HEALTH DEPARTMENT OR 
DFS WORKER. THEY BOTH HAVE ACCESS TO TERMINAL WHICH 
CAN DISPLAY INDIVIDUAL SERVICE FILE. 



REIMBURSEMENT FOR DIAGNOSIS AND TREATMENT 

DOCTORS AND DENTISTS WHO HAVE APPLIED FILL OUT REQUEST 
FOR PAYMENT FORMS. 

ALSO DOCTOR OR DENTIST CAN CHECK IF SUFFICIENT AMOUNT FOR 
EACH CHILD'S TREATMENT REMAINS OR SPECIAL REQUEST IS NEEDED. ' 



MSB FIRST CHECKS THAT A TRANSACTION NUMBER WAS ISSUED, AND 
THAT PROCEDURE AND AMOUNT IS CORRECT. 



DOCTOR MUST SUBMIT BILL WITHIN NINETY DAYS OF TREATMENT 
AND MUST OBTAIN A TRANSACTION NUMBER WITHIN SIXTY DAYS 
OF TREATMENT. 



DIAGNOSIS AND TREATMENT EVALUATION AND UR 

MSB PERFORMS UR PRIOR TO PAYMENT. 

MSB CAN SEND FIELD REPRESENTATIVES TO A PRIVATE OFFICE TO 
COMPARE CLIENT MEDICAL RECORDS WITH PROCEDURES CLAIMED ON 
SUBMITTED BILLS. 



MSB MANUALLY CHECKS EACH BILL FOR TRANSACTION NUMBER 
REQUEST, REIMBURSEMENT AND LIMITS ON PROCEDURES, AND HIGH 
VOLUME VENDORS. 



-26- 



ILLINOIS 



EPSDT RESPONSIBILITY 



A formal contract between the Department of Public Aid and the Depart 
ment of Public Health divides administrative and operational tasks. 
Public Aid is the Title XIX agency with administrative and fiscal 
responsibility. Public Health monitors screening, recruits 
screening providers, and evaluates screening. 






RIATIO 






LIU 




ORGANIZATION 



ILL TNCIS DEFA RTMEU' 


r OF ?: ; s 


LIC AID 


i ILIINOi 


'S DEPARTMENT OF PVSLIS --SALTS 


(ID? A) 






i 
1 


(mm. 


(TITLE XIX A, 


1EUCX , 




i 


A 



screening subcontract 



REGIONAL COORDINATORS 



_J 



INFORMATION FLOW 



STRUCTURE 

EPSDT INITIATION PLAMf! I MG AMD POLICY 



FILE SETS 



IDPA IS THE TITLE XIX AGENCY WITH ADMINISTRATIVE AND FISCAL 
RESPONSIBILITIES OF EPSDT. 

IDPA HAS SUBCONTRACT WITH IDPH FOR EARLY SCREENING AND 
PERIODICITY: 



- STATE PLAN (ES ?. P 

- MONITORING (ES £ P 

- EVALUATION (ES 3 p) 



IDPA AND IDPH 

IDPH 

IDPH 



TOGETHER IDPH AND I DP A DECIDE ON PROCEDURES AND REIMBURSE- 
MENT. 



QUARTERLY ESTIMATES OF ADMINISTRATION AND PROVIDER 
SCREENING COSTS ARE PREPAID TO IDPH EY IDPA. IDPH CO 
PUTES THIS ESTIMATE FROM THEIR BILLING MASTER. 



ELIGIBILITY DETERMINATION AND ID 



ER 



ELIGIBLES ARE CATEGORICALLY AND MEDICALLY NEEDY UNDER 
TWENTY-ONE. 

I DP A REDETERMINES ELIGIBILITY EVERY FOUR MONTHS. 



UPDATES ELIGIBILITY FILE ON IDPA COMPUTER. 

IDPA ISSUES NEW FAMILY MEDICAID ID CARD MONTHLY. 



PROVIDER RECRUITMENT 

SCREENING: IDPH ASSIGNS SCREENING VENDOR NUMBER TO COUNTY 
HEALTH CLINICS IF THEY QUALIFY. SCREENING MAY ALSO BE 
DONE BY LICENSED DOCTOR OR DENTIST WHO REQUESTS SCREENING 
VENDOR NUMBER, 



VENDORS FOR SCREENING ARE A VARIABLE ON IDPH BILLING 
MASTER. THEY ARE GIVEN A SPECIAL VENDOR NUMBER - 
NOT THE SAME AS MEDICAID VENDOR NUMBER. 



STRUCTURE 



FILE SETS 



DIAGNOSIS AND TREATMENT: ANY ILLINOIS CLINIC, DOCTOR OR 
DENTIST ELIGIBLE TO PROVIDE MEDICAID SERVICES. OUT OF 
STATE PROVIDERS MUST APPLY, 

REGIONAL COORDINATORS ENLIST NEW PROVIDERS. 



NOTIFICATION At ID SCHEDULING FOR SCREENING 

SOCIAL SERVICE WORKERS MAKE A HOME VISIT AND INFORM RECI- 
PIENTS WHERE APPOINTMENTS CAN BE MADE UFDC ELIGIBLES 
HAVE FIRST PRIORITY). 



IDPA MEDICAID FILE. 



MAINTAIN A HARDCOPY LIST AND UPDATE IDPH BILLING MASTER. 



IDPA PUNS PROGRAM USING ELIGIBILITY FILE AND SENDS LIST OF 
NEW ELIGIBLES TO SOCIAL SERVICE WORKERS. 



NO SHOWS AMD PERIODICITY 

SOCIAL SERVICE WORKERS RESPONSIBILITY. 



SUPPORTIVE SERVICES 

CONTACT: AT HOME VISIT BY SOCIAL SERVICE WORKER. 
TRANSPORTATION: SOCIAL SERVICE. 

FAMILY CASE HISTORY 

INFORMATION CASE HISTORY FILLED OUT AT HOME VISIT BY 
SOCIAL SERVICE WORKER. 



SOCIAL SERVICE WORKER FILES HARDCOPY. CASE IDENTIFICATION 
TRANSFERRED TO IDPA ELIGIBILITY FILE. 



REIMBURSEMENT FOR SCREENING 

SCREENING FORMS ARE SENT TO IDPH 

1) MEDICAL SCREENING FORM 

2) DENTAL SCREENING FORM 

3) VISION/HEARING SCREENING FORM. 



ALL ITEMS ARE ADDED TO CHILD SCREENING FILE ON IDPH 
COMPUTER. 

COST, PROCEDURE, DATE AND VENDOR NUMBER ARE ADDED TO IDPH 
BILLING MASTER. IDPH FIRST CHECKS MANUALLY AND MAKES 
PERSONAL CALLS IF ANY ERRORS ARE FOUND ON FORMS. IDPH 
THEN REIMBURSES VENDOR AT CUSTOMARY FEE OR MAXIMUM AMOUNT 
ALLOWED. 

FROM CHILD SCREENING FILE THE MEDICAL FOLLOW-UP REPORT IS 
GENERATED AND SENT TO SERVICE WORKERS. HARDCOPY IS ALSO 
KEPT BY IDPH FOR OPM REPORTS. 



SCREENING EVALUATION AND UR 

RESPONSIBILITY OF IDPH. CLINICS MUST HAVE WRITTEN 

LETTERS FROM DOCTORS AND DENTISTS SAYING THEY WILL TAKE 
REFERRALS. 



MEDICAL CASE HISTORY 

SCREENING FILE IS SEPARATE FROM DIAGNOSIS AND TREATMENT IDPH HAS CHILD SCREENING FILE. 

FILE. 

- HISTORY - TAKE INFORMATION OFF OF I DP A ELIGIBILITY 
FILE 

- MEDICAL RECORD 

- DENTAL RECORD 

- VISION/HEARING RECORD 



ADDITIONAL SCREENINGS ARE ADDITIONAL RECORDS, 



I DP A KEEPS SEPARATE MEDICAID TREATMENT FILE. 



REFERRAL FOR DIAGNOSIS AND TREATMENT 

CAN BE DONE BY DOCTOR OR AGENCY PERFORMING SCREENING. 

SOCIAL SERVICE WORKER CAN CHECK ON THIS BY ASKING FAMILY 
AND FILLING OUT MEDICAL FOLLOW-UP REPORT. 



A HARDCOPY OF MEDICAL FOLLOW-UP REPORT IS KEPT BY IDPA AND 
IDPH AFTER SERVICE WORKER HAS CIRCLED ACTION TAKEN. 



STRUCTURE 



FILE SETS 



REIMBURSEMENT FOR DIAGNOSIS AND TREATMENT 



forms are sent to idpa. 

1) physician's statement of services rendered. 

2) dentist statement. 

3) statement of optical goods and services. 



THESE FORMS ARE FIRST CHECKED MANUALLY BY IDPA THEN USED 
TO CREATE NEW MEDICAID TREATMENT FILE TO BE USED AS UP- 
DATE FOR OLD FILE. 

NEW MEDICAID TREATMENT FILE IS CHECKED AGAINST I 

- ELIGIBILITY FILE 

- PROCEDURE AND REIMBURSEMENT FILE 

- VENDOR FILE. 



IT IS THEN USED TO UPDATE PAYMENT HISTORY FILE AND REIMBURSE 
VENDORS. 



DIAGNOSIS AND TREATMENT EVALUATION AND UR 

RESPONSIBILITY OF IDPA. 

DENTAL BILLS ARE REVIEWED BY ILLINOIS DENTAL SERVICE.- 



-30- 



LOUISIANA 



EPSDT RESPONSIBILITY 



A recently formed social services umbrella agency, the Health and Social 
and Rehabilitation Services Administration, is the Title XIX agency 
in Louisiana. 

The Divisions of Income Maintenance and Health Maintenance and Ambulatory 
Patient Services function under formal agreements. IM retains administra- 
tive responsibility. HM performs screening through parish health depart- 
ments, billing the Division of Family Services for diagnosis and treatment, 
and IM for screening. The Health Departments bill IM for treatments that 
occurred as an outcome of a screening referral. 





HEALTH S SOCIAL & REHABILITATION 
SERVICES ADMINISTRATION 
(TITLE XIX AGENCY) 




DIVISION OF FAMILY SERVICES 
(FS) 



DIVISION OF HEALTH MAI NTESANCE 
AND AMBULATORY PATIENT SER7ICES 
(HM) 



L- — — — — — — — screening subcontract — 



J 



INFORMATION FLOW 



STRUCTURE 



FILE SETS 



EPSDT INITIATION, PLANNING AND POLICY 

IM SUBCONTRACTS TO H.'l TO PROVIDE EARLY AND PERIODIC 
SCREENING AND DIAGNOSTIC SERVICES, HM BILLS IM FOR 
THE COSTS O c THESE SERVICES AND FURNISHES FISCAL AND 
STATISTICAL I FORMAT I ON REGARDING THESE COSTS. 

FS IS BILLING BY PROVIDERS OF DIAGNOSIS AND TREATMENT 
EXCEPT FOR THE CASE WHEN A CLIENT WAS DIRECTLY- REFERRED 
BY HEALTH DEPARTMENT AND SFECIAL ARRANGEMENTS WERE MADE, 

SCREENING IS ACCOMPLISHED IN TWO VISITS. COMPLETION OF 
A MEDICAL HISTORY FORM, MEASUREMENTS , AND LAB TESTING ARE 
DONE DURING THE INITIAL VISIT, AN APPOINTMENT IS 
SCHEDULED FOR A RETURN VISIT WITHIN TWO WEEKS (AFTER LAB 
TESTS) FOR' A PHYSICIAN'S EXAMINATION, 



INCOME MAINTENANCE REIMBURSES ALL SCREENING COS'S AND SOME 
DIAGNOSIS AND TREATMENT BILLS. 



FAMILY SERVICES REIMBURSES ALL OTHER DIAGNOSIS AND TREATMENT 
BILLS. 



SCREENING FORM RECORDS EXACT TIME SPENT ON A CL". ENT BY EACH 
CATEGORY OF HEALTH DEPARTMENT EMPLOYEE. THIS ENABLES THEM 
TO COMPUTE EXACT SCREENING COSTS TO NEGOTIATE RATES. 



ELIGIBILITY DETERMINATION AND ID NUMBER 

RESPONSIBILITY OF FAMILY SERVICES. 
INCLUDES AFDC, FC AND SSI UNDER TWENTY-ONE. 



A CLIENT S ID NUMBER IS THEIR SOCIAL SECURITY OR PARENT S 
SOCIAL SECURITY NUMBER PLUS A TWO DIGIT CODE IDENTIFYING 
CHILD S BIRTH STATUS. 



FAMILY SERVICES SUBMITS AN UPDATED QUARTERLY LIST OF ELIGI" 
BLES TO HM WHO IN TURN SENDS LIST TO EACH PARISH HEALTH 
DEPARTMENT, 

FAMILY SERVICES PRODUCES THREE ID CARDS FOR EACH ELIGIBLE 
CHILD 

- ONE FOR CENTRAL CARD rILE KEPT BY HM 

- ONE FOR FS 

- ONE TO PARISH HEALTH DEPARTMENT. 



STRUCTURE 



FILE SETS 



PROVIDER RECRUITMENT 

SCREENING; HEALTH MAINTENANCE RESPONSIBILITY FOR SCREENING 
AND REFERRAL. 

DIAGNOSIS AND TREATMENT: USE TITLE V, STATE HEALTH PRO - - FS PROVIDER FILE 

GRAMS (TB, VD, HANDICAPPED CHILDREN AND DENTAL HEALTH), 
STATE INSTITUTIONAL CARE PROGRAM AND PRIVATE PHYSICIANS 
LICENSED BY STATE MEDICAL ASSOCIATION. 

- IM PROVIDES A LIST OF DENTISTS WILLING TO PARTICIPATE IN 
EACH PARISH. 



NOTIFICATION AND SCHEDULING FOR SCREENING 

INITIAL NOTIFICATION TO ALL ELIGIBLES AT INTAKE AND ONE COPY OF FORM IS KEPT BY SOCIAL WORKER AND ONE COPY IS 

RECERT1 FI CATI ON IS FOLLOWED BY PERSONAL CONTACT BY A SENT TO FS , 

SOCIAL WORKER. AT THIS TIME AN APPOINTMENT CAN BE MADE FOR 

INITIAL SCREENING AND THE SOCIAL SERVICE CERTIFICATION AND 

DISPOSITION FORM CAN BE FILLED OUT FOR EACH MEMBER OF THE 

FAMILY. 



NO SHOWS AND PERIODICITY 

PARISH HEALTH DEPARTMENT CAN INFORM PARISH SOCIAL WORKER THE PARISH HEALTH DEPARTMENT IS AWARE OF NO SHOWS SINCE 

OR THEY CAN CONTACT THE CLIENT THEMSELVES. SCREENING APPOINTMENTS ARE MADE. 



THE PARISH HEALTH DEPARTMENT KEE=S INDIVIDUAL MEDICAL FOLDERS 
WHICH CAN BE CHECKED FOR PERIODIC SCREENING. 



SUPPORTIVE SERVICES 

SOCIAL SERVICE WORKER HAS THE RESPONSIBILITY TO MAKE 
NECESSARY ARRANGEMENTS TO ASSURE THAT CHILDREN CAN GET 
TO SCREENING SITE. 

AFTER FIRST PART OF SCREENING, PARISH HEALTH DEPARTMENT 
IS RESPONSIBLE FOR MAKING ARRANGEMENTS WITH THE MOTHER AND 
CHILD TO GET BACK TO THE CLINIC. SOCIAL SERVICE WORKERS 
CAN BE CALLED UPON TO ASSIST IN PROVIDING THESE SERVICES. 



FAMILY CASE HISTORY 



SOCIAL SERVICES CERTIFICATION AND DISPOSITION FORM CONTAINS 
FAMILY HISTORY. 

CLIENT SERVICE PROFILE AND COPY OF SCREENING FORM (SERVICES 
RENDERED TO CHILDREN ELIGIBLE FOR EPSDT) . 



PART OF THIS FORM IS MACHINE READABLE AND CREATES AN INDIVI- 
DUAL RECORD ON FS SOCIAL SERVICE CASE FILE. 

KEPT AS HARDCOPY BY PARISH SOCIAL WORKER. 



REIMBURSEMENT FOR SCREENING 

AFTER SECOND PART OF SCREENING IS COMPLETED THE SERVICES 
RENDERED TO CHILDREN ELIGIBLE FOR EPSDT IS SUBMITTED TO 
INCOME MAINTENANCE FOR REIMBURSEMENT. 

NO DENTAL SCREENING - SEE DIAGNOSIS AND TREATMENT. 

SCREENING EVALUATION AND UR 

INCOME MAINTENANCE MAY AUDIT HEALTH MAINTENANCE RECORDS. 

HEALTH MAINTENANCE IS RESPONSIBLE FOR EVALUATING THE 
PARISH HEALTH CLINICS. 



INCOME MAINTENANCE FIRST CHECKS SCREENING FORM AND REIMBURSES 
BASED ON VALUE CODES ASSOCIATED WITH EPSDT PROGRAM. 

THIS FORM IS MICROFILMED AND STC3ED ON COMPUTER BY INCOME 
MAINTENANCE AND THEN SENT BACK TO PARISH HEALTH DEPARTMENT. 



MEDICAL CASE HISTORY 

THE MEDICAL CASE HISTORY FOLDER MAY CONSIST OF i ' HARDCOPY KEPT BY PARISH HEALTH CLINIC. 

- HISTORY TAKEN AT SCREENING 

- SCREENING FORMS 

- REFERRAL FORMS 

- TREATMENT FORMS BILLED TO HEALTH DEPARTMENT. 



STRUCTURE 



FILE SETS 



THE PARISH '.->C:AL WORKER ALSO RECEIVE A COPY OF SCREENING 
FORM TO BE 'EPT IN CASE FILE. 



REIMBURSEMENT FOR DIAGNOSIS AND TREATMENT 

DENTISTS MA V PROVIDE SPECIFIC SERVICES AFTER AGE TOO 
WITHOUT PRKR AUTHORIZATION. ALL DENTAL BILLS ARE SUB- 
MITTED TO FiMILY SERVICES. HEALTH DEPARTMENTS ARE 
REIMBURSED CM ACTUAL COST BASIS FOR TREATMENT . 

PRIVATE PROVIDERS WHO ACCEPT REFERRALS FROM SCREENING 
CAN BILL THE HEALTH DEPARTMENT OR DFS UNDER REGULAR 
TITLE XIX. 



DFS CHECKS BILLS MANUALLY AND REIMBURSES USUAL CUSTOMARY FEE 
OR FEE SCHEDULE (WHICHEVER IS LESS) . THIS IS STORED ON 
PHYSICIAN CLAIM FILE. 

TREATMENT BILLS SUBMITTED BY IM TO HEALTH ARE THEN SUBMITTED 
TO IM. THIS ALLOWS TREATMENT TO BE TIED TO SCREENING OUTCOME 



DIAGNOSIS A!.D TREATMENT EVALUATION AND UR 

DFS HAS COMMITTEE TO REVIEW BILLS FOR FRAUD. 



MANUAL CHECK FOR UNUSUAL BILLS. ALSO DFS CAN USE THEIR 
PHYSICIANS CLAIMS FILE TO IDENTIFY HIGH VOLUME VENDORS/ 
UNUSUAL PROCEDURE INCIDENCES, ETC. 



-34- 



NEW ORLEANS 



EPSDT RESPONSIBILITY 



The City of New Orleans Health Department is contracted by the Health 
and Social Rehabilitation Services Administration of Louisiana to pro 
vide EPSDT services to the city. The City Health Department bills 
HSRSA per visit by EPSDT eligibles. Under a DHEW grant, the city 
has developed a computerized data collection and billing system. 










ORGANIZATION 



HEALTH AND SOCIAL REHABILITATION 
SERVICES ADMINISTRATION OF LOUISIANA 
(HSRSA) 
TITLE XIX AGENCY 



I 



screening 
subcontract 



:JTY OF NEW ORLEANS 
HEALTH DEPARTMENT 



INFORMATION FLOW 



STRUCTURE 



FILE SETS 



EPSDT INITIATION, PLANNING AND POLICY 

HSRSA CONTRACTS WITH NEW O-.LEANS HEALTH TO PROVIDE 
EARLY AtO PERIODIC SCREENING AND DIAGNOSIS, AND TO BILL. 
HSRSA FOR THE COSTS OF SERVICES TO THE CHILD ON A PER- 
VISIT BASIS, NEW ORLEANS -EALTH DEPARTMENT WILL ALSO 
FURNISH HSRSA WITH FISCAL AND STATISTICAL INFORMATION 
AND ACCESS TO ADMINISTRATIVE HEALTH RECORDS. 



COOPERATIVE HEALTH I NFORf 1AT I ON SYSTEMS (d \E\i - HST-a) AWARDED 
NEW ORLEANS DEPARTMENT OF HEALTH A GRANT TO ESTA3LISH A COM- 
PUTERIZED DATA COLLECTION AND PILLING SYSTEM. 



ELIGIBILITY DETERMINATION AND ID NUMBER 

(AFDC, FC, AND SSI UNDER 21) 

A CLIENT'S ID NUMBER IS THEIR SOCIAL SECURITY OR PARENT ' S 
SOCIAL SECURITY NUMBER PLUS A TWO DIGIT CODE IDENTIFYING 
CHILD'S BIRTH STATUS. 



DIVISION OF FAMILY SERVICES UNDER HSRSA SUBMITS AN UPDATED 
QUARTERLY TAPE OF ELIGIBLES TO NEW ORLEANS. 

NEW ORLEANS UPDATES THEIR ELIGIBILITY FILE WEEKLY WITH THE 
DAILY UPDATES SENT BY FAMILY SERVICES, AND SENDS THIS LIST 
TO EACH OF THE TEN NEW ORLEANS HEALTH CLINICS. 



PROVIDER RECRUITMENT 

SCREENING AND DIAGNOSIS INCLUDING DENTAL SCREENING AND SOME 
SERVICES IS PERFORMED BY LOCAL HEALTH CLINICS. 



FURTHER TREATMENT IS PERFORMED BY TITLE V AGENCIES, STATE 
HEALTH FROGRAMS AND PRIVATE PHYSICIANS LICENSED BY STATE 
MEDICAL ASSOCIATION. 



STRUCTURE 



FILE SETS 



NOTIFICATION AND SCHEDULING FOR SCREENING 

PUBLIC HEALTH NURSES MAKE HOME VISITS AND EXPLAIN THE EPSDT 
PROGRAM. APPOINTMENTS CAN BE MADE AT THIS TIME OR THE 
PARENT CAN SCHEDULE OR JUST BRING THE CHILD FOR SCREENING, 



NO SHOWS AND PERIODICITY 

RECORDS ARE KEPT SY THE LOCAL HEALTH CLINIC AND THUS 
PERIODICITY SCREENING PROCEDURES CAN BE DETERMINED. 

IF AN APPOINTMENT IS SCHEDULED THE CLINIC CAN CHECK ON 
NO SHOWS. 



SUPPORTIVE SERVICES 

THE HEALTH CLINICS '.ORK IN CONJUNCTION WITH THE LOCAL 
SOCIAL SERVICE WORKER TO PROVIDE TRANSPORTATION AND 
DAY CARE. 



FAMILY CASE HISTORY 

THE LOCAL HEALTH CLINIC HAS THIS INFORMATION AVAILABLE THE PATIENT REGISTRATION FORM IS STORED ON TAFE AND UPDATED 

IN THE PATIENTS FOLDER. WHEN CHANGES ARE NOTED. 



REIMBURSEMENT FOR SCREENING 

NEW ORLEANS USES AN ENCOUNTER FORM TO RECORD ANY DELIVERY 
OF HEALTH CARE SERVICES BY A HEALTH CARE PROVIDER. 

SCREENING AND DENTAL ENCOUNTER FORMS ARE BILLED TO HSRSA 
UNDER AFDC. THE FIRST TIME AN INDIVIDUAL RECEIVES 
SERVICES FROM ANY A'GENCY IN THE CITY HEALTH DEPARTMENT'S 
HEALTH CARE DELIVERY SYSTEM THEY WILL BE REGISTERED BY 
FILLING OUT A PATIENT REGISTRATION FORM. (SEPARATE FORM 
FOR EACH ADULT AND CHILD) THE ID NUMBER RECORDED ON THE 
ENCOUNTER FORM MUST CORRESPOND WITH ID ON PATIENT'S 
REGISTRATION FORM, 



ENCOUNTER FORMS ARE FIRST SENT TO NEW ORLEANS CENTRALIZED 
HEALTH COMPUTER. THESE FORMS ARE FIRST CHECKED AGAINST THE 
ELIGIBILITY FILE AND REGISTRATION FILE. REIMBURSEMENT 
rjATES ARE THE SAME AS STATE OF LOUISIANA. THE ENCOUNTER 
FORMS ARE THEN USED TO UPDATE THE HEALTH MASTER, AND CREATE 
BILLING TAPE WHICH IS SENT TO HSRSA. 



SCREENING EVALUATION AND UR 

CITY OF NEW ORLEANS HEALTH DEPARTMENT HAS RESPONSIBILITY. 



MEDICAL CASE HISTORY 

LOCAL HEALTH CLINIC FOLDER HAS RECORD OF SERVICES RENDERED 
BY HEALTH DEPARTMENT. 



THE NEW ORLEANS HEALTH MASTER HAS A RECORD FOR EVERY ENCOUN- 
TER FORM SUBMITTED. THE PATIENTS PROFILE IS A REGULAR 
REPORT PRINTED BY THE COMPUTER AMD SENT TO LOCAL HEALTH 
CLINICS. 



REFERRAL FOR DIAGNOSIS AND TREATMENT 

EACH LOCAL HEALTH CLINIC MUST REFER CLIENTS TO AN THE PATIENT PROFILE REPORT SHOWS IF ANY FOLLOW UP IS 

AUTHORIZED PROVIDER FOR ANY NECESSARY FOLLOW-UP NEEDED. 

DIAGNOSIS AND TPEATMENT. IF A CLINIC DOES ANY TREATMENT 

OTHER THAN PROCEDURES REQUIRED UNDER EPSDT, IT SUBMITS 

AN ENCOUNTER FORM TO HSRSA AND DESIGNATES MEDICAID AS THE 

SOURCE OF PAYMENT. 



REIMBURSEMENT FOR DIAGNOSIS AND TREATMENT 

FURTHER TREATMENT PAY ALSO BE PROVIDED UNDER MEDICAID DFS CHECKS BILLS MANUALLY AND PFIMBURSES USUAL CUSTOMAPY FEE 

PLAN BY TITLE V AGENCIES, STATE HEALTH PROGRAMS AND OR FEE SCHEDULE (WHICHEVER IS LESS), THIS IS STORED ON 

PRIVATE PHYSICIANS LICENSED BY STATE MEDICAL ASSOCIATIONS, PHYSICIAN CLAIM FILE. 

BILLS ARE SUBMITTED TO LOU I S I ANA DI VI S I ON OF FAMILY 

SERVICES 



-37- 



OKLAHOMA 



EPSDT RESPONSIBILITY 



The Department of Institutions, Social, and Rehabilitative Services 
is the Title XIX umbrella agency in Oklahoma. 

No formal contract exists delineating EPSDT responsibilities within 
the agency, however, the Division of Assistance Payments determines 
eligibility. The Medical Unit performs UR and medical supervision, 
the Division of Social Services performs casework, and the Manage- 
ment Information Division maintains computerized EPSDT files. 





DEPARTMENT CF INSTITUTIONS, 
SOCIAL & REHABILITATIVE SERVICES 



MEDICAL UNITS 




DIVISION OF ASSISTANCE PAYMENTS 



MANAGEMENT 
INFORMATION 
DIVISION 



DIVISION OF 
SOCIAL SERVICES 



INFORMATION FLOW 



ST RUCTURF 



FILE SETS 



EPSDT INITIATION, PLANNING, AND POLICY 

NO FORMAL INTER-AGENCY CONTRACT. 

INFORMAL TASK FORCE OPERATING AMONG ALL THE DIVISIONS 
RESPONSIBLE FOR EPSDT ADMINISTRATION AND OPERATIONS. 



ELIGIBILITY DETERMINATION AND ID NUMBER 

ASSISTANCE PAYMENTS DETERMINES ELIGIBILITY EVERY SIX MONTHS. 
(AFDC, CUSTODY OF THE STATE OR FINANCIALLY ELIGIBLE FOR 
MEDICAL ASSISTANCE PROGRAM). 

AT ONSET OF ELIGIBILITY THE ASSISTANCE PAYMENTS WORKER FILLS 
OUT AN I NTRA- AGENCY REFERRAL FORM WHICH IS SENT TO THE SOCIAL 
SERVICE WORKER SHOWING IF THERE IS A NEED FOR SCREENING, 



THE CASE INFORMATION SYSTEM CONTAINS ELIGIBILITY INFORMATION. 
THIS SOPHISTICATED COMPUTER SYSTEM CROSS-REFERENCES ID NUMBER 
TO DETERMINE CLIENT'S PAST ELIGIBILITY. 



PROVIDER RECRUITMENT 

ANY MEDICAL OR OSTEOPATHIC PHYSICIAN AND DENTIST WHO SUB- 
MITS A BILL AND SIGNS THE MEDICAID AGREEMENT IS ELIGIBLE TO 
PERFORM SCREENING, DIAGNOSIS AND TREATMENT 



ONCE A PHYSICIAN OR CLINIC SUBMITS A BILL THEY ARE PUT ON THE 
PHYSICIAN CLAIM FILE. 

VENDOR NUMBER IS THEIR SOCIAL SECURITY NUMBER. 



STRUCTURE 



FILE SETS 



NOTIFICATION AND SCHEDULING FOR SCREENING 

UPON RECEIVING THE INTRA-AGENCY REFERRAL THE SOCIAL SERVICE 
WORKER WILL CONTACT THE RECIPIENT. AT THIS TIME THE 
SOCIAL SERVICE WORKER ASSISTS THE PARENT IN DETERMINING 
SCREENING MEED, SCHEDULING APPOINTMENT AND COLLECTING HEALTH 
HISTORY DATA. PARENT MUST SIGN FORM REQUESTING SCREENING. 
ONE COPY OF HEALTH HISTORY FORM IS PRESENTED TO THE DOCTOR 
AT SCREENING. 



SOCIAL SERVICE WORKER KEEPS HARDCOPY OF INDIVIDUAL HEALTH 
RECORD. THEY ALSO SUBMIT A SERVICE INFORMATION FORM SHOWING 
THE REQUEST FOR SCREENING OR REFUSAL OF SERVICE. 

THIS SERVICE INFORMATION FORM IS STORED IN THE CASE INFORMA- 
TION SYSTEM. 



SHOWS AND PERIODICITY 



RESPONSIBILITY OF SOCIAL SERVICE WORKER WHO CAN USE HIS OR 
HER FILES AND CLIENT STATUS REPORT, PHYSICIAN CAN 
ESTABLISH HIS OWN PERIODlCiTY SCHEDULE FOR ELIGIBLE CLIENTS 
(LIMITED TO ONE SCREEN/YEAO . 



EPSDT FLYER IS SENT TO RECIPIENT ANNUALLY ON THE ANNIVERSARY 
OF THE MONTH OF CERTIFICATION FOR ASSISTANCE. 



SUPPORTIVE SERVICES 



REQUEST FORMS CAN BE SUBMITTED BY THE CLIENT FOR TRANSPORTA- 
TION., DAY CARE, ETC. OR THE SOCIAL SERVICE WORKER CAN MAKE 
ARRANGEMENTS c OR SUPPORTIVE SERVICES INCLUDING PAID TRANS- 
PORTATION. 



REQUEST FORMS 
THE CLIENT. 



ARE ROUTED TO THE SOCIAL SERVICE WORKER FOR 



FAMILY CASE HISTORY 

THE PAYMENT ASSISTANCE WORKER OBTAINS THIS INFORMATION AT 
ONSET OF ELIGIBILITY, THE SOCIAL SERVICE WORKER CAN SUBMIT 
FORMS TO UPDATE THIS INFORMATION. 



THE MULTITUDE OF FORMS DOCUMENTING SOCIAL SERVICES COMPRISE 

A COMPLETE FAMILY HISTORY WHICH IS STORED AND CAN BE 

PARTIALLY RETRIEVED BY IBM DISPLAY TERMINALS UTILIZING THE 
CASE INFORMATION SYSTEM. 



REIMBURSEMENT FOR SCREENING 

PHYSICIANS FILL OUT PHYSICIANS SCREENING REPORT FORM (aDM-36"K) 
WHICH IS ALSO SIGNED BY PARENT. PHYSICIAN OR DENTIST SHOULD 
SUBMIT THIS REPORT WITHIN SIXTY DAYS OF SCREENING. 



EACH PHYSICIAN'S SCREENING REPORT FORM GENERATES FIVE DIF- 
FERENT RECORDS ON THE PHYSICIAN'S CLAIM FILE, REIMBURSE- 
MENT AMOUNTS ARE DETERMINED BY USING THE VENDOR FILE. THIS 
FORM IS ALSO USED BY THE CLIENT INFORMATION SYSTEM TO 
GENERATE AND UPDATE THE CLIENT STATUS REPORT WHICH IS SENT 
TO SOCIAL SERVICE WORKERS. 



SCREENING EVALUATION AND UR 

•UTILIZATION REVIEW THROUGH MEDICAL UNITS STAFF. COMPUTER PROGRAMS TO FLAG EXCESS BILLING AMOUNTS, MORE THAN 

ONE SCREENING PER YEAR AND IMPROPER SCREENING PROCEDURES. 

MEDICAL CASE HISTORY 

THIS IS KEPT BY PHYSICIAN AND SOCIAL SERVICE WORKER KEEPS THE PHYSICIAN'S CLAIMS FILE CAN BE SORTED TO PRODUCE A MED I - 

A FOLDER OF MEDICAL SERVICES PERFORMED AND/ OR NEEDED, CAL CASE HISTORY. 



REFERRAL FOR DIAGNOSIS AND TREATMENT 

DENTISTS MUST SUBMIT A NOTIFICATION OF NEEDED MEDICAL THESE ARE REVIEWED BY A DENTAL EVALUATION UNIT. 

SERVICES. 

THE PHYSICIAN WHO PERFORMED THE SCREENING CAN EITHER 
PERFORM TREATMENT OR REFER CLIENT TO ANOTHER PHYSICIAN, 
THE SOCIAL SERVICE WORKER CAN ASSIST BY USING THE CLIENT 
STATUS REPORT AND REFERRING THE CLIENT, 



REIMBURSEMENT FOR DIAGNOSIS AND TREATMENT 

THE PHYSICIAN OR DENTIST SUBMITS THE ADM-36-K BILLING 
FORM. 



EACH BILLING FORM GENERATES FIVE DIFFERENT RECORDS ON THE 
PHYSICIANS CLAIMS FILES. REIMBURSEMENT AMOUNTS ARE DETER- 
MINED BY USING THE VENDOR FILE. 



DIAGNOSIS AND TPEATMENT EVALUATION AND UR 



UTILIZATION REVIEW THROUGH MEDICAL UNITS STAFF. 



COMPUTER PROGRAMS FLAG MORE THAN FOUR OFFICE VISITS A 
MONTH, HIGH VOLUME VENDORS AND QUESTIONABLE BILLS. 



-40- 



SOUTH CAROLINA 



EPSDT RESPONSIBILITY 



A screening subcontract exists between the Department of Social Ser- 
vices (the Title XIX agency) and the Department of Health and Environ- 
mental Control. The former retains administrative responsibility and 
performs case work. The Department of Health provides screening throu 
local public health clinics. The Medical Assistance Section of DSS 
performs UR. 










TH C 








ORGANIZATION 



DEPARTMENT OF HEALTH AND 
ENVIRONMENTAL CONTROL 




MEDICAL ASSISTANCE 
(US) 



INFORMATION FLOW 



STRUCTURE 



FILE SETS 



EPSDT INITIATION, PLANNING AND POLICY 

DSS CONTRACT WITH HEALTH STIFULATES REIMBURSEMENT RATES 
FOR SCREENING. 



ELIGIBILITY DETERMINATION AND ID NUMBER 

DSS VERIFIES ALL ELIGIBILITY REQUESTS . ELIGIBILITY NUMBER 
IS NO"/ THE SAME A? PARENTS ' MEDICAID NUMBER. THEY ARE 
THINKING A30UT USING SOCIAL SECURITY NUMBER. 

CATEGORICALLY NEEDY ONLY. 



AN 
DAILY 



ATE ^SS ELIGIBILITY FILE. THIS PROGRAM ALSO GENERATES 
817 INITIAL SCREENING FORM, THIS FILE IS UPDATED 



PROVIDER RECRUITMENT 

SCREENING: DEPARTMENT OF HEALTH (ANY SOUTH CAROLINA 
LICENSED HEALTH CLINIC). 

DIAGNOSIS AND TREATMENT: ANY LICENSED DOCTOR OR DENTIST, 
IF DO NOT WANT TO BE PART OF PROGRAM THEY MUST REQUEST 
WITHDRAWAL. 



NOTIFICATION AND SCHEDULING FOR SCREENING 



DSS SENDS A LIST AT 1N-TAKE AND RECERTI F I CAT I ON TO THE 
CASEWORKER WHO SCHEDULES APPOINTMENTS. 



DSS USES ELIGIBILITY FILE TO NOTIFY CASEWORKER OF APPOINT- 
MENT REQUESTED. 



STRUCTURE 



FILE SETS 



NO SHOWS AND PERIODICITY 

THE CASEWORKER (DSS) MUST BE PRESENT AT THE SCREENING. DSS PRINTS-OUT SCREENING RESULTS FROM 817 SCREENING FORMS. 

ALSO AFTER NINETY DAYS THE CASE WORKER GETS A PRINT-OUT 
OF SCREENING RESULTS. 



PERIODICITY MUST BE CHECKED BY THE CASE WORKER. 



SUPPORTIVE SERVICES 

PAYMENT FOR TRANSPORTATION MUST (UNLESS EMERGENCY) BE 
PRE- AUTHORIZED BY DSS. DSS ARRANGES TRANSPORTATION WITH 
LOCAL OEO. 



DSS CONTRACT WITH OEO FOR TANSPORTAT I ON FOR ALL SOCIAL 
SERVICES, SCREENING HAS PRIORITY. 



FAMILY CASE HISTORY 

THE CASE WORKER COMPLETES A FORM AND KEEPS A COPY FOR HIS HARDCOPY OF CLIENT INFORMATION SUMMARY IS KEPT BY CASE 

RECORDS. WORKER AND DSS. 



REIMBURSEMENT FOR SCREENING 

TOP PART OF 817 SCREENING FORM IS FILLED OUT BY CLINIC AND 

SENT TO DSS. 



DSS CHECKS 817 FORMS AND DETERMINES REIMBURSEMENT AMOUNTS. 

SERVICE CODES, PROBLEM CODES AND VENDOR NUMBER ARE KEPT AS 
HISTORY RECORD ON EARLY SCREENING FILE (DSS) . 



DSS ALSO GENERATES A SCREENING RESULT PRINT-OUT SENT TO 
CASE WORKER, 



SCREENING EVALUATION AND UR 

IN CONTRACT DSS CAN INSPECT RECORDS OF HEALTH DEPARTMENT 
DURING NORMAL WORKING HOURS. 



HEALTH DEPARTMENT RESPONSIBLE FOR UR. 



MEDICAL CASE HISTORY 

THE DSS CASE WORKER KEEPS A HARDCOPY FILE. 



DSS EARLY SCREENING FILE CONTAINS ONE OF EACH: 

HISTORY RECORD WITH DATE, CASE, VENDOR, PROCEDURES AND 
PROBLEMS. 



DENTAL RECORD. 



DIAGNOSIS AND TREATMENT RECORD. 



PROCEDURE CODES CHANGE IF MORE THAN ONE TREATMENT IS NECES- 
SARY, HOWEVER, AMOUNT FOR SERVICE IS ACCUMULATED. EXCEPT 
AN ADDITIONAL RECORD IS GENERATED FOR EACH DIFFERENT PRO- 
VIDER FOR UR PURPOSES. 



REFERRAL FOR DIAGNOSIS AND TREATMENT 

UNLESS AN EMERGENCY THE SECOND PART OF THE 817 SCREENING 
FORM (PLAN OF TREATMENT) IS FILLED OUT BY A PHYSICIAN 
AND SUBMITTED TO DSS. 

(THE CASE WORKER MUST GIVE THE DOCTOR OR PARENT A COPY 
OF THE CHILD'S 817). 



DSS ADDS THIS TO DIAGNOSIS RECORDS OF EARLY SCREENING FILE 

AFTER IT HAS BEEN MANUALLY CHECKED. IF PLAN OF TREATMENT 

IS GRANTED THE 817 IS SENT BACK TO THE PROVIDER AND A COPY 
IS GIVEN TO CASE WORKER. 



REIMBURSEMENT FOR DIAGNOSIS AND TREATMENT 

THE DOCTOR OR DENTIST FILLS OUT THE BC/BS FORM. 



BC/BS PAYS DOCTOR OR DENTIST AND SUBMITS A TAPE TO DSS FOR 
REIMBURSEMENT, DSS UPDATES THE DIAGNOSIS AND TREATMENT 
RECORD ON EARLY SCREENING FILE. 



ALL DENTAL CLAIMS ARE DIAGNOSIS AND TREATMENT. 



DSS UPDATES THE DENTAL RECORD ON EARLY SCREENING FILE. 



DIAGNOSIS AND TREATMENT EVALUATION AND UR 

THE CASE WORKER HAS THE RESPONSIBILITY OF CHECKING IF 
TREATMENT IS COMPLETED. IF SO, THE LAST LINE OF THE 817 
SCREENING FORM IS COMPLETED AND SENT TO DSS. 



DSS CHECKS FOR MORE THAN FOUR VISITS PER MONTH OR $20 FOR 
PRESCRIPTIONS OR OVER $50 FOR A TREATMENT. THESE CASES 
ARE GIVEN TO THE UR COMMITTEE. 



-43- 



WASHINGTON 



EPSDT RESPONSIBILITY 



Washington coordinates its EPSDT efforts through three Divisions of the 
Department of Social and Health Services. Within this umbrella Depart- 
ment, the Office of Personal Health Services, under the Health Services 
Division, is the Title XIX agency. The Administrative Services Division 
assigns case numbers, the Division of Public Assistance performs case- 
work, and Medical Audit under DPA reviews provider claims. 





NG" 





INFORMATION FLOW 



STRUCTURE 



FILE SETS 



EPSDT INITIATION, PLANNING AND POLICY 

OFFICE CF PERSONAL HEALTH SERVICES IS THE TITLE XIX 
ADMINISTRATIVE AGENCY, THE MEDICAL CONSULTANTS, AS 
REGIONAL REPRESENTATIVES FOR THE OFFICE, ARE RESPONSIBLE 
FOR PRIOR MEDICAL AUTHORIZATION WHEN NEEDED, 



ALL BILLS ARE FISRT REVIEWED BY MEDICAL AUDIT STAFF AND 
THFN PROCESSED BY DIVISION OF PUBLIC ASSISTANCE. 



ELIGIBILITY DETERMINATION AND ID NUMBER 

LOCAL SERVICE WORKERS OF DSHS DETERMINE ELIGIBILITY 
FOR MEDICALLY AND CATEGORICALLY NEEDY. 



A FAMILY IS ASSIGNED A CASE NUMBER AND EACH INDIVIDUAL HAS 
A PIC NUMBER (INITIALS AND DATE OF BIRTH), THESE NUMBERS 
AND PERTINENT INFORMATION ARE COMPUTERIZED BY ADMINISTRA- 
TIVE SERVICES. LOCAL DSHS OFFICES ALSO ISSUE MEDICAL COUPON 
BOOKLETS - THESE COUPONS MUST ACCOMPANY VENDOR BILLS. 



PROVIDER RECRUITMENT 

there are four vendor id lists: 

- medical screening (health clinics and solo 
practitioners) 

- dental screening 

- medical diagnosis and treatment 

- dental diagnosis and treatment 



PERSONAL HEALTH SERVICES DETERMINES IF VENDOR IS ACCEPTABLE 
AND GIVES VENDOR NUMBER LIST TO DIVISION OF PUELIC ASSIS- 
TANCE. 



PROVIDERS MUST SIGN CONTRACTS AND SUBMIT THEM TO OFFICE 
OF PERSONAL HEALTH SERVICES. 



STRUCTURE 



FILE SETS 



NOTIFICATION AND SCHEDULING FOR SCREENING 

SCHEDULING OF APPOINTMENTS CAN BE HADE BY LOCAL DSHS EVERY SIX MONTHS DSHS SENDS FLYER ON EPSDT . 

CASEWORKERS, CLINICS ENROLLED FOR SCREENING, OR BY THE 
PARENT i 



NO SHOWS AND PERIODICITY 

LOCAL SOCIAL SERVICE WORKERS ARE RESPONSIBLE FOR NO SHOWS. A LOG OF SCREENING REQUESTS AND REFERRALS IS KEPT BY LOCAL 

THIS IS AN INFORMAL SYSTEM AND INDIVIDUAL PROVIDERS CAN ALSO DSHS OFFICE TO ASSURE RECEIPT OF SERVICES, THIS LOG CAN BE 

CHECK NO SHOWS AND PERIODICITY. AUDITED BY STATE DSHS, 



SUPPORTIVE SERVICES 

TRANSPORTATION REQUIRES PRIOR APPROVAL OF MEDICAL 
CONSULTANT OR LOCAL DSHS SERVICE WORKER. 



FAMILY CASE HISTORY 

RESPONSIBILITY OF LOCAL DSHS SERVICE WORKER. LOCAL DSHS SERVICE WORKER KEEPS A HARDCOPY FOLDER FOR EACH 

CASE. 



REIMBURSEMENT FOR SCREENING 

VENDOR SUBMITS EARLY SCREENING AND DIAGNOSIS BILLING 

FORM TO MEDICAL AUDIT SECTION. ATTACHED TO THE BILL 

MUST BE THE CLIENT ELIGIBILITY COUPON. 



MEDICAL AUDIT FIRST MANUALLY REVIEWS SCREENING FORM FOR UR. 
FORM IS THEN STORED ON PUBLIC ASSISTANCE BILLING FILE. 

PROVIDER MUST SUBMIT MONTHLY A STATISTICAL REPORT OF 
INDIVIDUALS RECEIVING SCREENING SERVICES. 



SCREENING EVALUATION AND UR 

MEDICAL CONSULTANT PERFORMS SITE VISITS FOR PARTICI" IF MEDICAL AUDIT FINDS UNUSUAL BILLS THE MEDICAL CONSULTANT 

PAT'NG HEALTH CLINICS. INVESTIGATES FOR DSHS. 



MEDICAL CASE HISTORY 

LOCAL DSHS WORKERS AND MEDICAL CONSULTANTS CAN REQUEST A 
PRINT OUT OF AN INDIVIDUALS RECORD OF ASSISTANCE PAID. 



PUBLIC ASSISTANCE CAN PROVIDE UPON REQUEST RECORD OF ASSIS- 
TANCE PAID FORM: 

- PROVIDER NUMBER 

- FROCEDURE CODE AND AMOUNT 

- DATE PAID, 



REFERRAL FOR DIAGNOSIS AND TREATMENT 

SCREENING VENDORS MUST BE ABLE TO REFER FOR FOLLOW-UP THIS INFORMATION IS TAKEN OFF OF SCREENING FORM AND INCLUDED 

TREATMENT, IN LOCAL DSHS LOG OF SCREENINGS RECUESTED AND REFERRALS. 

PRIOR APPROVAL FOR DENTAL TREATMENTS IS AUTHORIZED BY 
WASHINGTON DENTAL SERVICE. 



REIMBURSEMENT FOR DIAGNOSIS AND TREATMENT 

EVEN IF DIAGNOSIS AND TREATMENT TAKES PLACE AT SAME TIME 
AS SCREENING, TWO BILLS ARE SUBMITTED. 

A SEPARATE BILLING FORM WITH ATTACHED MEDICAL COUPON IS 
SUBMITTED TO MEDICAL AUDIT SECTION. 

DENTAL BILLING TO FISCAL INTERMEDIARY (WASHINGTON DENTAL 
SERVICE). 



DIAGNOSIS AND TREATMENT EVALUATION AND UR 



MEDICAL AUDIT MANUALLY CHECKS BILLS AND REIMBURSEMENTS ARE 
DETERMINED BY PROCEDURE CODES OR USUAL AND CUSTOMARY FEES 
(WHICHEVER IS LESS). THESE BILLS ARE THEN PROCESSED BY 
DIVISION OF PUBLIC ASSISTANCE AND STORED ON BILLING FILE. 



MEDICAL CONSULTANTS CAN PERFORM SITE VISITS TO HEALTH 
CLINICS PROVIDING DIAGNOSIS AND TREATMENT. 



IF MEDICAL AUDIT FINDS UNUSUAL BILLS OR HIGH VOLUME VENDORS 
THE MEDICAL CONSULTANT INVESTIGATES FOR DSHS. 



-46- 



MEDICAL CASE HISTORY 

Identifies content of records, organization of files, 
responsibility for maintaining and storing records, 
availability and access to patient profile. 

DIAGNOSIS AND TREATMENT REIMBURSEMENT 

Identifies who bills whom, fee schedules, what is stored 
from billing form, where it is stored and how eligibility 
is checked. 

DIAGNOSIS AND TREATMENT EVALUATION AND UTILIZATION REVEIW 
Who is responsible and how it is performed. 



It should be noted that information contained in the flow chart answers 
the first two objectives of the site visit, namely: 

Describe in place EPSDT efforts; 

Determine what data are being recorded. 
We have also organized the data presented in the flow chart into a set of 
decision matrices which permit examination of EPSDT components and data 
files by state. Appendix B presents the EPSDT State Data File Matrix, 
while Appendix C presents the EPSDT Component Matrix. 

'\,2 riFSPRTPTTON np STATE EPSDT STATUS 

In the effort to understand EPSDT, information from the MSA files were 
reorganized into seven categories under which may be subsumed all EPSDT 
functions. The categories listed are detailed in Section 3.1: 



Administration 



Financing 



Provider Agreements 




-47- 



Enrol Iment 



Screening Availability 



Diagnosis and Treatment 



Case Management 

In essence, these categories define the boundaries of a proposed class- 
ification system. That is to say, an understanding of the way in which 
EPSDT functions within these categories, the information which supports 
these categories, and the way in which this information is used to improve 
functioning within these categories defines both the EPSDT universe and 
the degree to which evaluation is taking and can take place. 

To further our understanding of the present status of EPSDT, we have taken 
the data from the interviews and reorganized it for discussion purposes 
into seven categories. At this time we plan to review the state status 
of EPSDT in terms of current structures and operations emphasizing the 
dynamic and evolutionary nature of EPSDT development. Included in this 
discussion is the identification of those barriers which mitigate against 
successful functioning within these categorical dimensions. It is expect- 
ed that this section will serve as the basis for a subsequent effort, name 
ly classifying data systems and files and their use in evaluation of EPSDT. 
This section of the report then also serves to fulfill our third objective: 
What uses are being made of EPSDT data? 

Parenthetically, it should be noted that these discussions do not identify 




-48- 



status and problems on a state by state basis. To the contrary, individual 
state identities have been submerged to maintain confidentiality of in- 
formation provided by state personnel. The reason is that this effort 
was not perceived as a state evaluation but instead was part of the effort 
necessary to build an evaluation system based upon the concept of informa- 
tion classification rather than specification. 

This mission was explained to state personnel' during site visits and we 
feel that this position resulted in our obtaining information which other- 
wise would not have been disclosed. To reiterate, the following sections 
describe the nature of structures extent in the states and the barriers to 
effective functioning without identifying specific states. 

4,2.1 ADMINISTRATION 

EPSDT administration and operations show a wide structural range across the 
states. Organizational structures range from highly centralized agencies 
to a diffusion of responsibility through a large number of pre-existing 
State Offices. These differences reflect organizational strengths which 
in turn are related to the operational interpretation of EPSDT. 

These bureaucratic differences serve to influence all program operations. 
In the course of this section the organization of EPSDT bureaucracy is 
detailed and its effects on policy, planning, objectives and information 
systems are considered. 




-49- 



EPSDT ORGANIZATIONAL STRUCTURES 

EPSDT activities are distributed under three headings: administration; 
medical services; and non-medical services. The distribution of activities 
follows: 



ADMINISTRATION 


MEDICAL AND DENTAL 
SERVICES 


i 

NON-MEDICAL SERVICES 


fiscal responsibility 


screening 


eligibility determination 


evaluation and quality 


diagnosis 


marketing and scheduling 


control 




reporting 


treatment 


support services 




provider enrollment 




case management 




provider reimbursement 






rates 







The administration and operation of EPSDT clearly involves a large variety 
of offices. The types of offices encountered in the eight states visited 
that perform direct or indirect EPSDT activities follows: 



ACTIVITY TYPE 


LEVEL OF 
OPERATION: 


ADMINISTRATION 


MEDICAL AND DENTAL 
SERVICES 


NON-MEDICAL SERVICES 


State 








Health and 
Welfare Divisions 


finance 

fiscal intermediary 
liaison 

data processing 


child health 
medical evaluation 
categorical programs 


public information 
field office supervisor 
eligibility determination 
social services 
EPSDT coordinator 


Other State 
Offices 


budget office 

treasurer 

controller 

governor 

0E0 






State Regional 
or County 


statistics 

billings 

records 


providers 

- public 

- private 


eligibility determination 
social services 
EPSDT coordinator 




-50- 



It can be concluded that the success of EPSDT requires a highly sophisti- 
cated level of coordination. 

Administrative and operational functions of EPSDT have been nested in three 
structures at the state level: Departments of Welfare; Departments of 
Health; and single state umbrella agencies which encompass both health^ and 
welfare. 

The single state agency for Title XIX in each state visited is either the 
Welfare Department or the umbrella department in which a Welfare Division 
is nested. Where formal agreements are in effect, the two agencies in- 
volved are Welfare and Health; the former retaining ultimate responsibility 
and authority. 

In the eight states, three independent Departments of Welfare and three 
Divisions of Welfare have entered into contractual agreements with corres- 
ponding Departments or Divisions of Health. In one state without a written 
agreement, authority resides in the umbrella agency per se rather than any 
division. In another state without a contract, authority for Title XIX 
resides in one office of the umbrella agency. 

Umbrella agencies offer an advantage over separate departments; namely, 
policy making for the large number of offices involved is centralized. 




-51- 



This increases the potential ease with which a comprehensive EPSDT effort 
may be integrated wi thin pre-existing bodies. It is no coincidence that 
two states which operate under umbrella agencies do not have formal 
interagency agreements. 

States which function with discrete Departments of Health and Welfare 
have a structural barrier to overcome in defining mutually compatible 
policies. Although each department can assign internal priorities, the 
interaction between departments dictates the existence of an outside 
arbiter to: resolve disputes. This arbiter is, logically, the State 
Executive. Thus, policy resolution occurs outside the normal bureaucratic 
channels and injects a great deal of potential political noise into policy 
definition and implementation. 

One important element of administration is the level of communications 
that exist between agencies. There are formal and informal means of 
maintaining -information flows, and all states necessarily operate under 
some functional information exchange system. The interagency task force 
as a formal body fulfills this need in one state, but another has a highly 
evolved informal system of phone, memo, and conference. This information 
process is critical for the effective integration of the EPSDT subsystems. 

Identifiable personnel assigned to EPSD1 are also si gni fi cant elements 
of administration. All states have mixes of personnel assigned solely 




-52- 



to EPSDT and personnel with shared responsibilities, but there are 
quantitative degrees of this. For instance, one state has fifty slots 
budgeted for EPSDT services, while others merely add on to existing 
worker responsibilities. These levels are important indicators of the 
degree of program function. 

Finally, EPSDT necessarily links public agencies with the private sector: 
medical providers, non-medical service providers, and fiscal intermediaries. 

In general what we have found is that despite the myriad of possible inter- 
actions between various agencies EPSDT can be described functionally under 
one of two operational definitions: 

- EPS plus Title XIX (EPS-DT) 

- EPSDT plus Title XIX (EPSDT-DT) 

In the former case the program is operated as early and periodic screening, 
or as early screening. The primary focus is directed to inputting children 
to screening with the expectation that providers already servicing Title 
XIX can be used for referrals. 

In the latter cases the program functions in a highly structured manner 
with well-defined linkages between screening, diagnosis and treatment. 
These programs may also permit screening, diagnosis and treatment to be 
provided concurrently through normal Title XIX channels. 




-53- 



The EPS-DT/EPSDT-DT groupings are identifiable levels of program develop- 
ment and integration in the eight states visited. There are six states in 
the first category and two in the second. The latter two operate under 
umbrella agencies, one with a formal interagency task force for EPSDT, the 
other with an intricate network of contacts among administrative personnel 
without formal departmental sanction. 

The other six states are divided between umbrella agencies (2), and dis- 
crete departments (4). None of these have formal task forces, but inter- 
agency contact is frequent if informal. 

OBJECTIVES AND MANAGEMENT PLANNING 

The objectives of the states visited cluster about two concerns: 
Threshold or Compliance 
Refinement or Maximization 

The former is identified by a concern with Federal sanctions - a problem 
for all states - while the latter defines its thrust as improvement of 
program effectiveness and efficiency. A listing obtained during the in- 
terviews and the number of states which articulated each follows: 

1. Compliance with Federal regulations (8 states). 

2. Screen a defined quota of eligibles (4 states). 
Allocate quotas by county (1 state). 

3. Implement periodicity quotas (1 state). 



B0K0N0N 




-54- 



4. Eliminate no-shows for screening (2 states). 
5 a Enroll adequate providers (2 states). 

6. Centralize EPSDT and integrate screening with 
diagnosis and treatment (3 states). 

7. Provide health education and related services 
(2 states). 

8. Improve record keeping and statistics (5 states). 

9. Improve evaluation (1 state). 



It must be added that all states could articulate any of these objectives. 
The importance of this distribution is that they are ones receiving 
priority attention from responsible authorities. 

The objective receiving the most mention is "Improve record keeping and 
statistics". As initial struggles with EPSDT are surmounted attention 
has been directed to problems of monitoring, evaluation and planning. 

One local project, encompassing a major population center, has evolved 
the rudiments of a highly sophisticated tracking and recording system 
to assist in planning. The project director hopes that his data base 

will permit determination of utilization and penetration amonq EPSDT 
eligibles allowing him unique opportunities to Dlan and estimate ser- 
vices and costs. 

Other states sense the opportunities inherent in efficient data collection 




-55- 



and are attempting to upgrade both hardware and software capabilities. 
(The flow charts display the current data capabilities of the states.) 

It is important at this time to emphasize the priority placed on this ob- 
jective by the states. This indicates the extent of future interest and 
suggests that more resources are becoming available in the states which 
will allow personnel to direct more and more attention to planning and 
data support systems. 

Management sjtyles evidenced were a rough mixture of "management by objec- 
tives" and "management by crisis" (this latter description given by one 
state official. 

Those states which indicated a detailed set of objectives (county quotas, 
follow-up refinements, record streamlining, etc) strongly endorsed the 
specification of benchmarks by which to monitor program attainment. But 
formal MBO systems seemed to be the bane of most of these states, oc- 
cuppying scarce staff in constructing and refining plans which they seem- 
ed to feel serve the needs of the political actors primarily. This view 
was expressed in at least three states, and there were intimations of 
similar views in other states. This feeling occurs whether or not a form- 
ally sanctioned MBO process existed. Finally, it should be recognized that 
since no agency functions devoid of expectations or outside direction, MBO 
is a functional presence in all states visited. 



BOKONON 




SYSTEMS 



-56- 



Management by crisis (MBC) is a more popular mode of operation in the 
states, if only because necessity so dictates. First, many personnel 
working in EPSDT have additional responsibilities. Accordingly their 
attention is diverted to which ever "squeaky wheel" squeaks loudest. 

Second; the rapid implementation of EPSDT in the wake of increasing 
Federal pressure and court suits produced uneven subsystems whthin the 
EPSDT network. Consequently, attention is often diverted to the most 
glaring deficiencies. This preoccupation with daily crises necessarily 
depletes attention otherwise available for systemic and future con- 
siderations . 

All states visited listed explicit objectives, however, it would appear 
that those they choose to articulate are highly indicative of the level 
of program evolution and refinement. Thus, an initial and struggling 
EPSDT effort might set a blanket quota of "everybody we can get to screen- 
ing," whereas a more refined effort is capable of specifying screening 
quotas by county. 

Finally the extent to which objectives are specified may be seen as an 
indicator of program confidence and direction, stemming in Dart frnm the 
quality and currency of information available to administrators and 
planners . 




INFORMATION SYSTEMS 



All eight states have sophisticated computer capability. However the range 
of information systems in place was enormous, Nevertheless the hardware 



The real problems lie in the diffuse and fragmentary way in which EPSDT 
information systems have been developed. These problems may be described 
as follows: 



the data for all aspects of EPSDT may be in two or 
more computers in separate agencies. 

the software has not been developed to adequately 
store, sort, and integrate the various files on 
which EPSDT is based. 

the data requirements, and the modes of analysis 
have not been adequately defined. 



No aspect of EPSDT is under greater scrutiny. The reason being that as 
EPSDT operations have mushroomed, so has the volume of data and the re- 
quests for compilations of that data. It is impossible to overemphasize 
the importance of quality information to any program evaluation model. 
The importance is recognized in the states, and great efforts are being 
made to develop systems tailored to the unique needs of EPSDT. 

The computers available at the state level represent vastly disparate tech- 
nical capabilities. The implication of these differences for EPSDT, how- 
ever, are not all that important because of the serial nature of the files 



is adequate for any analytic procedures which might be requested. 




-58- 



maintained. Much more important is the access EPSDT personnel have to the 
equipment. For example, states with umbrella agencies may have centralized 
computer facilities serving users from all social service programs which 
increases distance between users and programmers and counters the advantages 
of a unified data system. In other instances we found that two states 
with discrete agencies have two separate computers, one in health and one 
in welfare further confusing data consolidation. 

Another comol.i cation occurs in the state? which use fiscal intermediaries 
for dental or medical services. In at least three states, three com- 
puters are processing data from separate aspects of EPSDT. These states 
are in the throes of attempting to integrate their separate files, but if 
the experience in other states is any guide, the lag time may be upwards of 
18 months to two years. If this holds true for these states, the prob- 
ability is that less evolved states will not have integrated information 
systems for several years to come. 

This finding has grave implications for Federal monitoring efforts, and 
reinforces the notion that a data classification system which is built 
upon present capabilities holds more hope for success than data specifica- 
tion models. Particularly since the need for evaluation is immediate and 
cannot be deferred, say four to five years. 




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There are several files involved in EPSDT data processing across the states, 
however, they may be subsumed under four basic categories. These are: 



eligibi li ty fi le 

client history 
vendor file 
screening claims file 
diagnosis and treatment claims file 



While the need for these four, files is clear, the lack of integration of 
them within the states remains a problem despite the level of program 
sophistication. 

Aside from problems of separated files, the data also exists in different 
forms from state to state and level to level within a state. Two states 
have a computerized record of every screening transaction that has oc- 
cured since EPSDT was implemented. Others are far short of this, and range 
from computerized records of current eligibles down to hard copy records in 
local office case files. Accordingly, in all but two states, the bulk of 
important data is presently stored in hard copy. What this means is that while 
there is sufficient data to fullfill any evaluation request, one must re- 
cognize the level of effort needed to create new data files and integrate 
them with existing ones. 

States are becoming, aware of these conditions and working to develop sys- 
tems with one or more of the following capabilities: 




-60- 



combine screening with diagnosis, treatment files 
to produce a client medical profile. 

combine medical records with client case records, 
including eligibility, to assist in providing con- 
tinuity of care across transient eligibility. 

provide on-line remote access to county level. 

provide a tracking, on-line remote systems capable 
of tying diagnosis and treatment to screening re- 
ferrals to assure proper follow up. 

maximize centralization of data and computer utili- 
zation. 

acquire a computer solely for EPSDT. 



None of these objectives is immediately attainable. Beyond the time nec- 
essary to develop software and acquire hardware are additional barriers: 
the distance between systems personnel and EPSDT personnel decreases access 
and increases the time necessary to complete a task; technical differences 
such as vendor procedure codes; integrity of data collection; and integration 
of traditionally separate bodies of data which are not amenable to intuitive 

or obvious resolution. Finally, specif.yinq data needs mav require a com- 
bination of decisions and agency politics, a tandem that is rarely congruent 
within timetable expectations. 

Parenthetically, it should be noted that one local project has developed a 
comprehensive EPSDT data collection and analysis system. The activities be- 
ing coded are the same as those in other states indicating the possibilities 
for success of such efforts. 




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Using a centralized computer facility, the project maintains an eligi- 
bility file, patient registration file, and a health master file. The 
latter is a record of all patient encounters billed through Medicaid. 

The records kept are adequate to have produced the following reports 
on EPSDT uti lization: 



patient profile 
registrations by census tract 
morbi di ty i n ci den ce 
distribution maps 

registrations by census tract provider 
clinic utilization by census tract 
purpose of encounter by disposition 
immunization by census tract 
diagnosis by census tract 
services rendered by clinics (monthly) 
daily encounter summary 
daily registration summary 
diagnosis frequencies by provider 
registrations by clinic 
age-race-sex profile by clinic 



This project indicates that it is a long way from the perfect system, but 
these studies are profoundly meaningful to resource allocations, budget de- 




-62- 



termi nations , and other objectives. Such an effort is an adequate demonr 
strati on that there are no real technical barriers to systems evolution. 

Finally we would like to point out that the core of any evaluation model is 
the data base. In this light it is important to recognize the extent of 
present state capabilities? Four states have highly evolved data systems, 
yet only one state and the aforementioned local project are beginning to 
use the data for planning purposes. However, system designs oeing con- 
templated for implementation will be accompanied by an increased use of 
data for planning and analysis purposes. In those states where designs 
contain descriptions of available data and the uses to which this data is be 
being put, we have indicated them in the State Flow Charts. It seems, how- 
ever, that for present purposes, the answer to our third objective "what 
uses are being made of the data" is "very little." 

SUMMARY 

An overview of EPSDT administration, therefore, reflects a range of in- 
terpretations of the legislation, from distinct programmatic efforts to add- 
ons to existing structures. These EPS-DT and EPSDT-DT efforts, however, 
cannot be interpreted solely in light of authorities and offices. 

Less tangible are the historic committments the individual states are 
prepetuating. Histories of strong public health, charity hospitals, 
or provision of physician care to the poor are reflections of political 




-63- 



will that have been focused by EPSDT requirements* The ultimate impact 
of EPSDT will derive not from administrative structures, per se, but 
from the strength of the determination to fulfill the mandates of EPSDT. 
This commitment is demonstrated by one state's EPSDT objective; "to 
screen every eligible child and insure proper treatment". The strength 
of such a declaration clearly overcomes the bureaucratic structures that 
fulfill operational and administrative functions. 

States with centralized responsibilities in the bureaucracy are seeking 
further centralization to facilitate integration of the EPSDT sub- 
systems, but policy and planning considerations must concern internal 
program goals and the relationship of the program to the greater environ- 
ment. Thus, one state official explained that responsibility and author- 
ity had been spread throughout the state umbrella agency because if too 
many offices feel left out of a program those offices stimie any initia- 
tives on behalf of the program. An official in another state referred 
to the constant conflict over interpretations of EPSDT as "a termite war". 

All states indicated that the governor's budget office was their major bete 
noir in terms of money and resources. The budget office directly reflects 
the priorities of the governor, and thus in those states where EPSDT is 
considered a high priority item among all state social services programs 
(perhaps six of the eight visited) the budget office is the primary deter 1 , 
minant of resource allocations. This will be discussed further under 




-64- 



financing below, but it may be pointed out here that although monies for 
provider reimbursement were nowhere found to be in short supply, authori- 
zations for support staff were. 

The administration of EPSDT can be viewed, then, as a mixture of pre- 
existing bodies with special offices or positions created to fill the gaps. 
Some EPSDT efforts retain their add-on orientation, at least two have assum- 
ed somewhat independent and programmatic status. As immediate imple- 
mentation requirements are met, renewed interest in planning has been 
stimulated. This in turn, has led to a re-evaluation of data structures 
and requirements. Although the realization of planned information systems 
may be years in the making, the emphasis being placed on these needs now 
heralds a cleaner data base from which evaluation may proceed. 

4,2,2 FINANCING 

No element so pervades the effective functioning of EPSDT as financing. 
There are three types of costs associated with EPSDT: direct medical ser- 
vices, direct non-medical services, and administration. A summary of in- 
formation collected reveals that: 



There is no shortage of funds for provider reimbursement 
although states close to the 50% matching figure are some- 
what more concerned than others. 

There are shortages of government personnel to deliver non- 
medical support services, as well as concern over the pro- 
vision and funding of such support services as transportation 
and child care. 




-65- 



There is a shortage of administrative personnel at the 
state level. 

There is a general difficulty in breaking out EPSDT 
costs, particularly in relating D&T to screening re- 
ferrals, and in figuring administrative overhead. 



The total costs of EPSDT are difficult to compute in any state. Provider 
reimbursement costs for screening are the easiest to derive. More dif- 
ficult to ascertain are diagnosis and treatment costs as a consequence of 
screening outcomes, and indirect costs. 

Screening reimbursement rates vary greatly both between and within some 
states. The rates are of two types: per capita and per procedure. 
Medical screening rates range from $8.50 for an initial screen to $27.50 
although one state is proposing a clinic rate several dollars higher than 
this latter figure. Only one state has a flat per capita rate, the others 
pay additional amounts for special tests or procedures. Rescreening rates 
range from $6.30 to $22.50. 

Dental screens range from $5.00 to $18.00, with extra fees in some states 
for bite-wing x-rays, prophylaxis, or flouride treatment provided during 
the screening. Two states bypass dental screening altogether in favor 
of referring all eligibles for diagnosis and treatment and thus do not 
have a screening rate. Two others incorporate an examination of the mouth 
into the medical screening. 




-66- 



The provider reimbursement rate times the number of clients screened or 
procedures performed produces a sub-total of screening costs. Although 
totals were not available for all states, it would appear that with 
a single exception states have not expended or projected expenditures 
in excess of $2.5 million for the present annual year, a figure which 
includes the Federal share. 

Non-medical services such as transportation or day care are also part of 
EPSDT expenditures, but they are generally not recorded as such. Trans- 
portation which must be provided to eligibles who request the service is pro- 
vided in a wide variety of ways. One state has signed a contract with an 
0E0 project to provide transportation for all social service pro- 
grams. Other states rely on case worker automobiles, cash allowances 
in the welfare grant or voluntary agencies to carry clients to the screen- 
ing appointments. The provision of transportation in all but one state 
is rather ad hoc and informal, the bane of cost accounting. No state pro- 
vided transportation expenditure data. The fact that many clients are some- 
how making it to the provider suggests that either the need for transpor- 
tation is limited or that the posts are negligible enough not to warrant 
efforts at special appropriations to cover the need. The latter explanation 
is probably closer to the truth. 

Data on other support services costs were unavailable. One state claimed 
that every activity associated with EPSDT could be cos ted, but no data was 
provided. 




-67- 



Caseworker costs are not always charged to EPSDT. One state charges all 
caseworker costs to the Welfare Department, another two charge them to 
Title IV(a) funds. One state has the capability to compute exact persons 
costs because part of each client's screening record notes the amount of 
time each category of worker spent with the client. 

Although caseworkers are devoting large amounts of time to EPSDT proces- 
ses, few states currently possess the capability to determine the costs 
that could be charged to EPSDT. The multiplicity of duties and services 
performed by caseworkers mitigates against any easy solution. However, 
those states where EPSDT caseworkers are a line item in the budget (2) 
this difficulty could be largely eliminated. 

The provision of diagnosis and treatment as a result of a screening 
flag represents the greatest challenge to accounting for the costs of 
EPSDT. Diagnosis and treatment reimbursements are, of course, readily 
available, but the link to screening is generally either very weak or 
non-existant. This is a problem directly traceable to the quality of 
the records maintained and the degree to which the various records are 
centralized and computerized. This will be discussed in greater detail 
in further sections. Suffice to say that unless referral records show 
the abnormality detected in screening, and the physician's treatment 
records are tied to that referral form, then there is no means to dis- 
criminate between diagnosis and treatment from screening and other diag- 
nosis and treatment. 




-68- 



There are four states in which treatment may occur at the same time as 
screening, and this represents a partial solution to linkage with D&T. 
No state, however, provided any D&T cost estimates or expenditures arising 
from screening. The increasing sophistication of record keeping for 
screening examinations is not being matched by sophisticated linkages with 
treatment records. 

One state was able to specify its EPSDT administration costs, while another 
state did provide an estimate. Both figures ran to approximately 3% of 
total costs. One other state claimed the ability to break out adminis- 
trative costs, but figures were not offered. Two states said that "frankly 
we have no idea." 

Accounting systems are being planned to identify administrative costs, but 
the accuracy of the figures will depend upon the quality of records and the 
degree to which EPSDT is submerged in other Title XIX activities and ac- 
counts. 

MEDICAID DOLLAR 

Medicaid dollars receive various priorities among the total dollars avail- 
able from Federal and state programs. One state explicitly uses Medicaid 
as the last dollar, another designates Medicaid as the first dollar. One 
other state designates Medicaid as a "semi -last" dollar, with specific 
provider resources listed to be charged first. Three other states indicated 
a desire for Medicaid to be first dollar but coordination with other health 




-69- 



programs was poor and hence billing from them was sporadic. 

This relates to the problems of equivalent care discussed under screen- 
ing. All but two states are very concerned about using Medicaid dollars 
to free up categorical funds to expand services to the marginally non- 
eligible populations. Currently, however, the state of records and ac- 
counting permit no estimates to be made of categorical dollars that could 
be billed to Medicaid. 

SUMMARY 

Costs of EPSDT, with the exception of screening, are difficult if not im- 
possible to determine. Administrative costs are submerged in other 
budgets making it difficult to assess without establishing appropriate 
cost accounting systems. 

The biggest difficulty lies in determining D&T costs because of the lack of 
intergation of screening and D&T files. This problem makes it difficult 
if not impossible to separate D&T costs resulting form screening from 
those which result from "episodic" encounters. 

Finally it should be noted that the use of Medicaid as first health dollar 
is not always the rule. As a result, this has increased the difficulty 
of intergrating other Federal financed health program servicing children 
into the EPSDT structure. 




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4,2,3 PROVIDER AGREEMENTS 

Provider participation in EPSDT is critical. Few states have sufficient 
public medical resources to provide screenings, and none can provide all of 
the treatments covered under their State Medicaid Plans. Hence a variety 
of methods have evolved to attract providers into servicing EPSDT. 

Most states separate enrollment for screening vendors from enrollment for 
diagnosis and treatment. Accordingly, these two processes will be con- 
sidered independently. 

SCREENING 

Three states which use county health departments for medical or dental 
screening merely extend the agreements between state health and welfare 
departments to service EPSDT. One state, which relies almost entirely 
on solo practitioners, does not have proprietary contracts. Instead, 
each signed bill submitted represents a unique and separate agreement. 

Four states which use a broad mix of vendors to provide screening employ 
varying enrollment methods. Three states use formal agreements: in one 
state between the Title XIX agency and the provider; in the other two states 
between the health department and the provider. One state supervised pro- 
gram enrolls through the health department using eligibility standards. 




-71- 



The eligibility requirement for screening is approximately the same • 
from state to state: license to practice medicine in the state. Clinics 
are subject to a more rigorous process often entailing site visits and ex- 
tended questionnaries to determine clinic capabilities. This process ob- 
tains for local health departments, Title V agencies and NHC's. One state 
requires all screening providers to prove that licensed medical facilities 
have agreed to accept referrals from the screening vendors. 

DIAGNOSIS AND TREATMENT 

Enrollment of providers for D&T services is usually separate from that 
of screening. In at least three states, all eligible to perform diag- 
nosis and treatment may screen, but not all screeners may perform diag- 
nosis and treatment. One state uses its health department to provide a 
major protion of diagnosis and treatment except for dental service which 
is provided by private practitioners. This functions through formal con- 
tracts between the health and welfare departments at the state level. In 
one state, a private fiscal intermediary handles enrollment. In three 
states, any licensed provider may submit bills for diagnosis and treatment. 

The contracts are typical of Title XIX and are written to preclude fraud 
rather than to specify type or quality of service. Review procedures, 
reporting requirements, and vendor freedom of choice are essential parts 
of the contracts. 




-72- 



Diagnosis and treatment record requirements are generally more detailed 
than for screening records - the number of disorders possible, for in- 
stance, guarantees the use of a complicated set of codes. The billing re- 
cords are the primary source of client medical information at the state 
level. Only two states can provide on a routine basis a cumulative re- 
cord by patient of all claims tendered via Medicaid. Other states are 
working toward this capability. 

VENDOR IDENTIFICATION NUMBERS 

Vendor identification numbers are assigned separately for Medicaid diag- 
nosis, treatment and screening in one state. Another state uses the 
provider's Social Security number, two others use the state license num- 
ber, and other states assign numbers serially. One state has two parallel 
series of numbers, one for medical providers, one for dentists. Thus, 

two providers may have the same number, and only a determination of which 
service type was provided identifies the type of provider. 

All states maintain computerized vendor files to check eligibility and 
to assist in UR. 



Despite the ease of enrollment, states indicate that provider availibility 
continues to be the main problem in implementing EPSDT. It might be in- 
teresting to analyse both screening and D&T data as a function of providers 



SUMMARY 




-73- 



to determine the extent to which provider availability has hampered pro- 
gram implementation. 

Finally, it should be noted that as economic conditions continue to decline 
changes may occur. While it is true that financial incentives in terms of 
amounts have not seemed to increase participation, the very fact that 
Title XIX is able to pay rapidly in some states may become an incentive 
which will result in changes in provider service patterns where EPSDT 
eligible populations are concerned. 

4,2,4 CLIENT ENROLLMENT 

The first services performed under EPSDT are those necessary to enroll 
clients: identifying eligibles; notifying eligibles; scheduling appoint- 
ments; providing supportive services; and re-scheduling for broken appoint- 
ments. The compliance mandates specify that each eligible case be notified 
at least once annually in writing of the availability of EPSDT services 
and that transportation be provided for those in need. Beyond that, the 
states are essentially left to their own methods of linking the eligible 
population to screening services. 

ELIGIBILITY 

Eligible populations are clearly defined in the State Medicaid Plans, but 
the problem of locating those eligible children in need of EPSDT is more 
complex. Those children enrolled in categorical aid programs are readily 
identifiable through case lists. A more subtle problem is locating those 




-74- 



children eligible as medically needy under the state plan. This issue 
is not yet being vigorously pursued in the states concerned, mainly be- 
cause of the priority assigned to AFDC recipients. 

A severe complication arises in targeting specific eligible sub-pop- 
ulations for EPSDT activities. The importance of this issue cannot be 
overemphasized when considering the longitudinal delivery of child pre- 
ventive health services. Large but indeterminate portions of Medicaid 
eligible children are already receiving some form of medical services 
through Title V programs, state school health programs, state public 
health programs, other Federal categorical programs, and private providers. 
Of the states visited by Bokonon, only one has seriously addressed the 
question of equivalent services outside the structure of EPSDT. 

Yet this targeting is critical to the efficient operation of an EPSDT 
effort, particularly to the process of allocating scarce resources and 
minimizing cost. If children already under some form of health care receive 
screening services, the opportunity cost is high. Not only has effort and 
expense been duplicated but likely to detriment of one not receiving care. 
In an environment of scarce availabilities, this is an especially ineffie- 
ient use of resources. Thus, the current absence of a refined technique 
for breaking out sub-populations of unserved children from the gross eligi- 
bility files represents a most significant barrier to delivering EPSDT 
health services and of planning for future resource needs and allocations, 
locations . 




-75- 



The gross eligibility pools for EPSDT are, in all states, compiled by 
the regular eligibility determination offices of the state welfare depart- 
ments. In state administered-local ly supervised Medicaid Plans, the 
eligibility files are centralized and computerized at the state level. 
At least annually, the states produce master lists of eligible cases. 
These lists, however, are updated monthly, weekly, or in two cases, 
daily. These central files are helpful in tracing transient cases 
through time, a capability discussed later. Eligibility lists are 
provided to local social service workers by the state social service 
agency in two states. The state social service agency provides local 
health departments with current eligibility lists in three states. 
Local or district offices product their own lists in three states. 



Translating the gross eligibility pool into an effective outreach effort 
varies from state to state. The outreach responsibilities primarily fall 
to social service workers at the local level, although two states coor- 
dinate heavily with the screening providers (the local departments of 
health). Where there are several public and private screening providers, 
this coordination does not exist except in relation to broken appointments 
(no-shows ) . 

All visited states rely upon the certification or recertifi cation in- 
terview to inform the clients of service benefits and procedures. Thus, 



OUTREACH 




-76- 



a client may well be aware of EPSDT services prior to formal enrollment 
into the eligibility pool. Home visits by social service workers in two 
states supplement the interview information. Two states take the opportunity 
of the certification interview to determine whether or not 1 the eligibles 
under 21 are receiving equivalent screening care. This is a potentially 
significant cue for sorting eligibles for more intensive outreach efforts. 
One local site uses public health nurses to perform outreach through 
home visits. 

Written mailers are generally regarded as ineffective as outreach materials 
relative to personal contacts. All states comply with Federal Regulations: 
notices are sent on an annual or bi-annual basis. Written materials 
are also available at various social service agencies. These brochures 
and leaflets contain information about what EPSDT services are available 
and how to obtain them. Four states have used the media to inform el- 
igibles, mainly through interviews or feature stories in local papers or 
by producing spots aired as public service announcements. 

There is no concensus among the states about the effectiveness of outreach. 
There is an intuitive feeling on the part of many state officials that perso- 
nal contact generates the' highest return. But it becomes extremely dif- 
ficult to link outreach procedures and outreach effectiveness because of the 
breadth of differences that exist from state to state on scheduling procedures. 




-77- 



SCHEDULING 

Scheduling activities vary greatly from state to state. One state in- 
forms eligibles when they are scheduled for screening, three others pro- 
vide a list of three providers to each family and the family is primarily 
responsible for scheduling with screening providers. The remaining four 
states place primary responsibility for scheduling with the social service 
worker. 

In any state, however, a family may seek a screening appointment 

on its own initiative, either directly with the provider or through the 

caseworker. 



Formal responsibility for rescheduling no-shows lies with the social service 
caseworker in all states, although in three this function overlaps with 
specific screening providers, i.e., local health departments. The case worker 
is notified by the provider of the broken appointment. One state over- 
schedules its health clinics to assure maximum utilization of facilities. 
Two states admit that rescheduling is an informal system, left to the 
discression and agression of the caseworker and the provider. 

It is interesting to note that one state has sub-contracted all outreach 
services in a major metropolitan area to a local welfare reform organization. 



NO-SHOWS 




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The contract has not been in effect long enough to determine the effec- 
tiveness of this process but the state is hopeful of increasing the 
penetration rate through this method. 

PERIODICITY 

Periodicity has been officially implemented in only one state: quotas have 
been set by county. In other states, periodicity is in effect only to the 
extent that eligibles themselves request re-screening. This is because 
initial screenings have not been completed on the total eligible popula- 
tion. At least two other states plan to implement periodicity plans, but 
not for fiscal 1975. All states have a recommended periodicity schedule 
but one state allows the screening vendor to set periodicity as needed by 
an individual client. 

Determining the penetration rate of these outreach activities has been 
very unsuccessful to date. Only one state includes equivalent care in its 
reported total screened for the 0PM Quarterly Reports. One state believes 
that EPSDT merely formalizes a system of provision of care to the poor 
that has existed since the state was founded. The question of equivalent 
care receives varying answers state to state. One state includes all Title 
V enrol lees as receiving equivalent care, another excludes all Title V as 
being inadequate. The enormous number of health care dollars and pro- 
grams available to the poor are obscured by programs such as vision and 
hearing screening that are available to all children in a state. 




-79- 



Currently, no state is fully confident that the number of eligibles 
across time can be fixed, or that equivalent care issues can be re- 
solved. The improvements forthcoming in automated records and unified 
filej may ease this condition, but there are no easy solutions to de- 
termine the penetration rate. Yet this measure is clearly of paramount 
importance in program evaluation. 

SUPPORT SERVICES 

Support services are the responsibility of the local social service 
workers in all states. The most common services provided are transportation 
and day care for children. As mentioned, one state has sub-contracted all 
transportation to the state 0E0 for all social services, with EPSDT the 
primary priority. Two states require prior authorization if transportation 
costs any money; another one provides fur.ds as part of the cash welfare 
grant. All states emphasize that wherever possible, family or voluntary 
agencies provide services, this in line with a welfare philosophy that 
stresses minimizing client dependency on public agencies. 

4,2.5 SCREENING 

The primary EPSDT thrust at present is directed toward screening. The 
reasons for this hinge upon the delays in initiating the program coupled 

with recent Federal and legal pressures. It is interesting to note, however, 
that despite the pressures states have implemented screening in ways which 
typically reflect their past history in health delivery. These methods 
range from exclusive use of solo providers to increasing capabilities 




-80- 



of local public health programs. 

In this section we attempt to review screening efforts with particular 
attention to providers, data files and the uses of the information gathered. 



Three states rely entirely on local public health departments for medical 
screening which reflects the prominent position public health has occupied 
in those states for several decades. Four states use public health clinics 
when available, and one state relies almost entirely on solo practitioners. 

The four which use some local public health agencies also use clinics, school 
health programs, Title V programs, HMO's, and private practitioners. 

Dental screening is by-passed in one state (all children are sent directly 
to D & T), another uses public health dentists and six use private dentists. 

Most states complete screenings in one visit except when special tests are 
needed. One state has a vision and hearing screening program for all 
children, so that three separate screenings are needed: vision and hearing, 
medical and dental . 

Provider availability (enrolled providers) was cited as a major problem 
in one state and all states noted difficulties in rural areas. In addition 
all states indicated a shortage of dental providers. 



PROVIDERS 




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In one state mobile units for both medical and dental screening were in opera- 
tion and further expansion was being considered to meet rural needs. In 
another state dental service was being expanded by the use of mobile units. 

While some states were considering transportation alternatives, all were 
closely watching the use of mobile units as a solution to the problem of 
screening. 

States have attempted to use financial incentives to increase provider 
participation. This has taken two forms: generous flat fee for screening 
and rapid payment. 

Despite these efforts no data is available which indicates the effects of 
financial incentives upon provider participation. It is possible, however, 
that during these trying economic times, high reimbursement rates and 
rapid payment may lead to increased provider participation. It is important 
that if this occurs a close watch on uti lization patterns of former users 
is maintained to determine if the incentives are serving to withhold medi- 
cal care from these other populations. 

SCREENING PACKAGES 

The screening packages were similar in the states visited with Federal 
guidelines setting standards. In general differences reflected local emphasis 
rather than content: testing for lead poisoning in older urban areas; 
sickle cell testing for blacks, etc. 




-82- 



The major differences between the states lie in the use of personnel 
involved in screening and their level of activity. While most states rely 
on non-providers for patient history these may range from nurse practi- 
tioners to specially trained para-professionals. Much discussion was found 
concerning the allocation of screening activities to non-medical personnel 
although no general theme could be ascertained. 

USE OF OTHER HEALTH PROGRAMS 

Screening children does not operate exclusively through Title XIX. Title V 
and state health programs preceeded EPSDT by many years. However, coordina- 
tion between EPSDT and the range of child health programs is somewhat 
restricted in the states. Federal policy makes it impossible for school 
districts to be reimbursed from Title XIX funds for services otherwise 
rendered free of charge. The wide range of Title V efforts means that 
equivalency determination by the enrollment agencies occurs generally on a 
case by case basis. On the other hand, preventive programs such as PKU 
testing, vision and hearing screening, and immunization programs are easier 
to incorporate into the EPSDT process. 

Nonetheless, the state EPSDT programs are not confident of their relation- 
ship to other programs. The reasons are many: conflicting administrative 
domains.; ambiguous regulations; lack of file interfaces; and political 
factors. The mandate for EPSDT clearly implies coordination with 
existing services, but, the nascent EPSDT effort has not formally chosen 




-83- 



between the poles of coordination and programmatic service delivery. 
DATA FILES 

Screening records are of mixed quality and availability. Three states use 
a billing form that contains only a procedure code to discriminate 
between an initial screen and a periodicity check. Four states use a 
billing form that records procedures performed during screening. However, 
only one state computerizes all the procedures performed. 

A client's screening record generally remains within the domain of the 
provider. Even where the screening procedures are detailed, the degree of 

abstraction that occurs in the computerization of data makes analysis and 
aggregation of information difficult. There is also the problem of split 
files, i.e. part of the client history remains in the case file, part in 
the screening form, and part in the billing file. 

Despite the problems and with the exception of the three states which only 
code screening as an encounter, screening information is available and 
accessable. Even the three states have hard copy of screening events 
stored. Increased file unification and more thorough computerization of 
records (processes in progress in every state) should reduce the difficulty 
of ascertaining screening procedures and outcomes. 




-84- 



E VALUATION 

The evaluation of screening is mysterious territory to most states. All 
states have utilization review as required in state plans, with medical 
units assigned to perform the task. 

The means of performing evaluation depend upon the type of screening pro- 
viders used in a state. Five states who use some form of clinic for some 
or all screenings conduct site visits of clinics to check for adequacy of 
the facility, record keeping, etc. All states check for fraud, over 
utilization, bizarre billing patterns and duplicate claims. 

No one is satisfied with the means of evaluation available, especially as 
regards solo practitioners. The sad fact is that the heart of EPSDT - the 
early screening of children - remains without an acceptable and successful 
means of evaluating the quality of service. 

Equally unknown to date are false negative and false positive rates of 
referral from screening. If treatment can be tied to screening referrals, 
the latter problem is resolved. As for the former - no one has been able 
to offer a solution short of re-screening. But this raises the issue of 
cumulative error rates, and no state has found a means of determining this 
f i gure . 




-85- 



4,2,6 DIAGNOSIS AND TREATMENT 

The intent of the EPSDT legislation is obtained when and if screening identi- 
fies health problems which in turn are confirmed through diagnosis and 
subsequently receive treatment. The impact or success of the program 
lies in an ability to show that early detection of morbidity (for which 
there is treatment) and its treatment leads to decreases in long term 
debilitating chronic illnesses. 

The program has not been in existance long enough to examine its impact. 
However, D & T can be considered in terms of efforts which by definition 
are required for EPSDT. These are: 

- D & T interface with screening. 

- Provider availability. 

- Data files. 

- Evaluation of D & T. 

DIAGNOSIS AND TREATMENT INTERFACE 

The linkages between screening and diagnosis and treatment within the states 
leaves much to be desired. With the exception of those states where 
screening, diagnosis and treatment can occur simultaneously who receives 
diagnosis and treatment after screening cannot be determined. This is 
further compounded by children who do receive treatment during screening 
for which no bill or report is prepared (one state estimated that fully 
one-third of those who were screened received some form of treatment 




-86- 



during screening which was not reported). 

Those states where screening and diagnosis and treatment function separately 
have the most problems. The present approach is to attempt to match 
positive screening profiles with D & T claims which are billed in the next 
ninety days. This method is filled with pitfalls: some public and private 
providers are as far as six months behind in billings; the billing forms 
are not specific enough to discriminate an "episodic" encounter from a 
referral etc. 

One state has obtained a partial solution to this problem by requiring 
a treatment plan except in emergencies to be submitted for approval. 
However, this has been accompanied by minor treatments being performed 
without being recorded and by an apparent increase in "emergency" treatment. 

Only one state requires a treatment claim to indicate that it resulted 
from an EPSDT referral. 

Case workers appear to function effectively through screening but, their 
efforts in referral through D & T appear limited. 

Accordingly, it can be concluded that the data describing EPSDT D & T is 
fragmentary and inaccurate. 




-87- 



PROVIDERS 

D & T provider participation suffers from problems similar to those in 
screening: limited participation; shortages in rural areas; and a general 
shortage of dentists. 

D & T is provided on the most part by solo providers under regular Title XIX 
rules. Additional service is obtained through the use of Title V programs 
(mostly well baby and Child and Youth projects) and by state categorical 
health programs such as: T.B.; V.D.; lead poisoning, etc. Six of the 
eight states have one or more such programs in operation. 

Those states which have histories of strong public health programs are 
attempting to expand services by increasing public health capabilities. We 
found increased use of mobile health delivery units, particularly dental, 
in both rural and urban areas. 

In states where sole practitioners offer most of the service financial 
incentives are in use or planned to increase participation. In the main 
these consist of improving payment time lag by insuring rapid payment. 
While this does not appear to have had a major effect to date it is entirely 
possible that as general economic conditions worsen, this will serve to 
increase participation. 



EVALUATION 

Evaluation of diagnosis and treatment like that of screening is limited and 




-88- 



reflects the state of the art. In the main efforts are directed to 
Utilization Review processes and are most effective in limiting fraud. 
These activities typically: review high volume vendors; respond to reci- 
pient complaints; consider questionable bills; and respond to other profes- 
sional complaints. 

In addition, several states have initiated prior treatment authorization 
plans to limit excessive payments. These plans are also reviewed for 
adequacy of proposed treatment and so serve as a possible quality control. 

One state uses two methods of evaluating dental care. First, a child dental 
profile is being added to the client record to verify the need for treat- 
ment for a given tooth. If the tooth was removed, it clearly is not in 
need of a filling, etc. In the second method, a mobile unit is beginning 
to visit areas of the state to check the teeth of all children in an area 
for whom a bill was submitted in order to verify that the specified treat- 
ment was actually performed. 

In addition to these efforts, almost all states which use clinics had a unit 
which periodically carried out site visits to observe clinic functions. 
These programs serve as quality control only in the most rudimentary terms. 

No state appeared to have a long range approach to the use of D & T data 
for evaluation. Nor was any state considering the relationship of treat- 




-89- 



ment to outcome as a possible measure of the impact of EPSDT. 
DATA FILES 

The quality of D & T data files varied widely. Examination of the flow 
charts and the State Data File Matrix (appendix B) provides a detailed des- 
cription of what is presently in place. 

While continuity of data between screening, diagnosis and treatment is the 
most prevelant problem (note section on screening, and diagnosis and treat- 
ment linkages) the most serious one is that resulting from the controversy 
surrounding the use of procedure codes. While it is recognized that with- 
out proceedure codes no real analysis of D & T can take place, arguments 
continue concerning which coding system to use, to what level of detail > 
etc. 

We found one state using three codes, others which had prepared their own 
and a general lack of consensus about which to use. Moreover one state 
reported that despite having medical society approval for the code finally 
selected over 70% of treatment billings were listed outside the codes as 
"other". 

One final note, since all states have extensive UR procedures, most of the 
data presently stored is accurate and up to date. 




-90- 



4,2,7 CASE MANAGEMENT 

In addition to specifying health care requirements, the uniqueness of EPSDT 
as a Title XIX program is indicated by guidelines which specify case 
finding activities. Not only is a level of health service delivery speci- 
fied, but case management activities to insure health delivery are also 
detailed. Accordingly, operational responsibility for assuring client- 
EPSDT activities has become the charge of social service caseworker. 

State EPSDT objectives intimately involve case workers. Screening and 
periodicity quotas, reduction of no-shows, follow-up on screening referrals 
and rapid screening of the newly eligible are all dependent upon the 
quality of case management. Thus, there is pressure within several states 
to allocate specific employees to EPSDT activities. Currently, only one 
state visited employs case workers specifically for EPSDT. This initiative 
runs counter to another tendency in the states, that of reducing expendi- 
tures for welfare. Accordingly, most states have added EPSDT activities 
to the caseworker's present job responsibilities. This cross-current 
operates to the detriment of EPSDT in general and case management per- 
sonnel suffer the brunt of this imposition. 

An essential long range objective of EPSDT is to alter the utilization 
patterns of the client population from episodic to preventive care. 
Health education and nutrition programs are under consideration in 
several states toward this end, and integration of similar programs 




-91- 



that already operate is a distant objective. The personnel tagged to 
perform educational services not currently available under existing programs 
are the caseworkers. Since the ultimate success of EPSDT depends in no 
small part upon the patterns developed by the eligible population (self- 
scheduling, for instance) these programs are of great consequence to the 
future of EPSDT. 

State efforts in case management were found to function in one of two ways: 
continuous or segmented. In the former, a particular caseworker maintains 
supervision and responsibility throughout all stages of a client's progress 
through EPSDT. The latter is obtained by segmenting responsibility among 
several agencies or individuals according to which portion of the EPSDT 
process the client is negotiating. 

The following sections discuss case management activities observed during 
the site visits. 

ENROLLMENT 

Generally, eligibility was found to be determined by special certification 
employees or by regular social service workers, although in one state, 
both initial and re-certification were the responsibility of a separate 
agency. 




=92- 



Social service workers continue their involvement and are responsible for 
notifying and scheduling eligibles for screening. This entails a broad 
variety of activities: 



Identification of eligibles 
Notification of eligibles 
Scheduling appointments 
Provision of supportive services 
Re-scheduling for broken appointments. 



Each of these functi ons has been detailed as to procedure and responsibility 
under 2.2.4, Client Enrollment. However, it is important to note that 
even in those states where case management is segmented, the social ser- 
vice worker still maintains a level of responsibility since EPSDT is among 
client services. 

Since the target, population has generally had little or no experience with 
health delivery systems, the quality of guidance rendered by case workers 
is critical to client enrollment and participation in EPSDT. The degree 
of case management responsiveness to client needs is a major determinant 
of EPSDT penetration rate. 

SCREENING - DIAGNOSIS & TREATMENT LINKAGE 

The single most important effort among the case manager's activities is 
to insure that children referred for an abnormality receive diagnosis and 
treatment. Although two states require the screening vendor to perform 




-93- 



this service, the remaining six states list this as an activity of the 
social service worker. In addition, as part of their regular on-going 
casework effort, the social workers are required to arrange for subsi- 
diary services such as transportation and day care as well as to be 
responsible for the paper-load required by these services. 

No matter who is responsible for insuring the linkage among screening, 
diagnosis and treatment, cooperation between screening vendors, case 
workers and diagnosis and treatment vendors is necessary. The linkage 
between the case worker and diagnosis and treatment vendors becomes even 
more important in those cases where treatment requires a series of visits. 

To aid the caseworker in determining which children require referral to 
diagnosis and treatment and to insure that D & T takes place, one state 
attempts to provide the caseworker with an indication of the screening 
referral and subsequently to indicate whether or not a bill has been sub- 
mitted for treatment of that client. This match of the D & T payment 
files with screening referrals is being considered narticularly in those 
states which presently maintain separate screening and D & T files. 



Client tracking is a major concern in all states. Procedures for referral 
are present in all states, however, use is voluntary in most states and 
the results are reported and stored into a data system in only one state. 



TRACKING 




-94- 



Two states specifically reported that they lacked the authority with which 
to require local offices to maintain referral procedures and forms. 
However, every state has an adequate case or client identifier with which 
to track an individual through the various files - the client identifica- 
tion code. Thus, the means for automated queing and tracking exist in all 
states, but was not in use in most states visisted (seven). 

PERIODICITY 

Periodicity management is distributed variously. All states have established 
periodicity schedules, although one state allows the screening provider 
to establish periodicity on a case by case basis. One state presently 
is undertaking rescreens according to their periodicity schedule with the 
state responsible for client identification. In the other states (7), 
periodicity is essentially left to client initiative, caseworker initiative, 
or provider initiative - a very personal system. Ultimate responsibility 
lies with the notification and scheduling agency with one exception - one 
state makes periodicity the responsibility of the screening provider 
following the initial assessment. 



It was clear from our visits that institutional or personal style of case 
management does determine the level of success of EPSDT efforts. Case- 
workers in both welfare and public health departments have enormous per- 
sonal latitude in carrying out activities necessary to channel children 



SUMMARY 




-95- 



into EPSDT and shepherd them through the entire cycle. It would seem 
that the passivity or aggressiveness of case management can transcend any 
structural limitations, perhaps more so than any other component within 



The major problem faced by the case manager in carrying out efforts lies 
in the lack of an organized file system which would permit appropriate track- 
ing of client status. In one state, we observed the rudimentary development 
of an on-line client information system which permits caseworkers to call 
up client data through the use of remote terminals. Clearly, such a system 
would maximize EPSDT efforts by making clear the status of EPSDT eligibles 
on a client by client basis as opposed to gross totals typically reported 
by states. 



EPSDT. 




I . 



APPENDIX A 
STATE AND LOCAL QUESTIONNAIRES 



BOKONON 




STATE QUESTIONNAIRE 



OBJECTIVES 

What are the state's objectives for EPSDT for this year, for this quarter? 

What does full implementation mean to you? 

When do you expect to be fully implemented? 

Who is pressing for full implementation of EPSDT? 

Are there people opposed, who? 

Who is responsible for evaluation of objectives? 

How is this done? 

May we have copies of planning and policy documents which identify your 
objectives; for example do you prepare a proposal each year? 

Documentation: Planning, and policy documents. 
STATE EPSDT ROLE 

What are the responsibilities of the state agency for monitoring EPSDT 
implementation? 

May we have copies of the relevant guidelines? 

How are local efforts evaluated: 

- outreach 

- screening 

- diagnosis and treatment 

- follow-up? 



What authority does the state agency have to order alterations in local efforts? 

How does EPSDT relate to Medicaid? 

Is EPSDT a separate administrative unit? 

What is the role of EPSDT in the state Medicaid plan? 

Documentation: State Medicaid plan 

EPSDT guidelines and authority. 

INTERAGENCY RELATIONSHIP 

Do you have any relationships with other programs which provide medical services 
for chi Idren? 

Are these formal, if so, do you have copies of the formal arrangements? 
Documentation: Formal agreements. 

OUTREACH 

Do you have a plan for identifying eligibles, what is it? 

Are you responsible for notification? If yes, how do you do it? 

SCREENING PROCEDURES 

How many have received a complete screeninq to date? 

What are the components of a screening? 

Who establishes that? 

Who establishes the periodicity schedule? 

May we have copies of the periodicity schedule? 

Documentation: Screening manual and referral standards 

Incidence data. 



SCREENING EVALUATION 

Who evaluates adherence to screening standards? 
How is this done? 

Is there any means of establishing a false positive rate? False negative rate? 

May we have copies of any evaluation designs used or being planned? 

Documentation: Screening standards and procedures manual 

Evaluation designs 

DIAGNOSIS AND TREATMENT 

What standards for treatment exist? 

Who establishes these standards? How is treatment reviewed for quality? 
How is diagnosis and treatment billed? 

Can client progress through treatment be tracked by the billing system? 
How are specific diagnoses recorded? 

Is the billing system used to provide feedback to case managers on client progress? 
How? 

Documentation: Standards and procedures manual 

PSRO plan, etc. 

DATA SYSTEMS 

What is the system for processing EPSDT data? 

Is there a centralized state data system? Is one planned? 

If not, how are state data collected? 

What reports have been derived from available data? 

May we have copies of these reports? 



How long before client data are entered into your data system? 

Are EPSDT records maintained separately from the regular Medicaid files? 

Is there anything on a Medicaid record to indicate client participation in EPSDT? 

What happens to client data during periods of Medicaid ineligibility? 

What systems exist to check the accuracy of recorded data? 

What links exist between information system and the case management? 

Documentation: All data forms used transmit data on clients including 

screening outcomes and billing, and systems manuals 
for either computer or hard copy system. 
Computer specification including program source and 
sample output. 

CO ST DATA 

What is the total number of state personnel assigned to EPSDT? 

What is the total budget? 

May we have copies of your budget? 

Documentation: Budgets. 
May we have a copy of this year's Medicaid budget? 
Is EPSDT a distinct part of Medicaid budget? 

Where are the total resources available for EPSDT including state appropriations, 
local appropriations, volunteer time, and overlaps with pre-existing children 
and youth programs? 

How much has EPSDT added to existing social service administration costs? 



How much does a single screening cost, including outreach screening, and case 
management? 

What data are available on cost effectiveness? May we have any documentation on 
cost effectiveness studies? 

How much do cost considerations impede implementation? 

What would full implementation of EPSDT cost? 

Documentation: Budget for Medicaid and EPSDT 

Cost agreements with other agencies 

Cost effectiveness procedures and studies 

Fee schedules 

Procedures for reimbursement. 



PROVIDER AGREEMENTS 

How many providers are enrolled for EPSDT screening services? 
How many do you need for full implementation? 

Do you have any cooperative arrangements with the state Medical Society or any 
other medical society, may we have copies of these agreements? 

Is there any physician resistance to participation in EPSDT? 

What are the reasons for this? 

Documentation: Provider agreements with the EPSDT agencies 

Medical Society agreements with EPSDT agencies 



CASE MANAGEMENT 

What agency is responsible for case management? 

If more than one agency is responsible for case management what are the divisions 
of res pons i bi li ty? 

May we have copies of any guidelines or inter-agency agreements pertaining to this 

What agency is the repository for client records? 

Documentation: Case worker guidelines 

Interagency agreements 
Client forms. 



LOCAL PROJECT QUESTIONNAIRE 



OBJECTIVES 

What are your objectives for EPSDT for this year, for this quarter? 

What does full implementation mean to you? 

When do you expect to be fully implemented" 

Who is pressing for full implementation of EPSDT? 

Are there people opposed, who and why? 

Whc is responsible for evaluation of objectives? 

How is this done? 

May we have copies of planning and policy ciocuments which identify your 
objectives, for example do you prepare a proposal each year? 

Documentation: Planning, and policy documents. 
ORGANIZATIONAL ROLES 

Who is responsible for EPSDT activities? 

Do you have functional descriptions of all ^taff members, may we have copies 
of these descriptions? 

Documentation: Staff descriptions. 
I NTER-AGENCY __R_ELAJI : ONSHI PS 

Do you have any relationships with other Ircal children and youth Droarams? 

Do you have any relationships with other programs which provide medical services 

Are these formal, if so, do you have copies of the formal arrangements? 

If yourarrangements with other children anc ! youth projects are informal ■ could 
you please describe them? 

Documentation: Formal agreements 



OUTREA CH 

What processes do you use to identify eligibles? 
How often do you upgrade this process? 

Are .there any sub-populations selected for intensive outreach? Which are they? 
Who notifies eligibles? 

What means are used to notify them? May we have copies of any written material 
or notification guidelines? 

What assures that eligibles receive some form of notification? 

How are enrol lees in other child programs included in the notification process? 

What problems remain in notifying eligibles? 

What percentage of total eligibles have been notified? 

What percent have expressed an interest in being screened? 

Documentation: outreach material 

state mandate 
guidelines 
procedures 
staff assignment. 

SC HEDULING 

Who is responsible for making appointments for screening? 

How many no-shows for appointments have occurred? 

What are the procedures for following up broken appointments? 

May we have copies of any guidelines describing any of these procedures? 

Documentation: Instructions to appointment makes including 

no-show procedures and statistics on appointments 
made, no-shows and target quotas. 



SCREENING PROCEDURES 

How many have received a complete screening to date? 

How many screenings -a day are being done? 

What are the components of a screening? 

How many screenings a day can be done? 

How long does a complete screening take? 

Who determines that? 

May we have copies of the screening and referral standards manual, registration 
forms, medical records, reimbursement forms, referral forms, and permission 
forms, as well as instructions on their proper routing? 

To what providers are positives referred? 

Are screening and diagnosis occurring simultaneously? 

Who establishes the periodicity schedule? 

May we have copies of the periodicity schecule? 

Documentation: Screening manual and referral standards 

Clinic forms detailed above 
Incidence data. 

SCREENING EVALUATION 

Who evaluates adherence to screening standards? 
How is this done? 

May we have copies of any documents or guidelines pertaining to UR or PSRO? 

Is there any means of establishing a false positive rate? Flase negative rate? 

Are clients records used to evaluate screening? 

How is this done? 

Who does it? 

May we'have copies of any evaluation designs used or being planned? 

Documentation: Screening standards and procedures manaul 

Evaluati on designs . 



DIAGNOSIS AN D TREATMENT 

What is the lag time between a positive screening and an appointment for 
diagnosis? 

Does treatment begin at the same time diagnosis occurs? 
Is parental permission necessary prior to treatment? 
Is agency permission necessary prior to treatment? 
What standards for treatment exist? 

Who establishes these standards? How is treatment reviewed for quality? 

Documentation: Standards and procedures manual 

PSRO Plan, etc. 

DATA SYSTEMS 

What is the system for processing EPSDT data? 

What reports have been derived from available data? 

May we have copies of these reports? 

How long before client data are entered into your data system? 

Are EPSDT records maintained separately from the regular Medicaid files? 

Is there anyting on a Medicaid record to indicate client participation in EPSDT? 

How does the system operate to identify clients whose time for a health assess- 
ment has come again? 

What happens to client data during periods of Medicaid ineligibility? 

What systems exist to check the accuracy of recorded data? 

What links exist between information system and the case management? 

Documentation: All data forms used to transmit data on clients 

including screening ™.!tcr»mps and billing, and 
systems manuals for either computer or hard copy 
system. 

Computer specification including program source 
and sample output. 



CO ST DATA 

What is the total number of staff assigned to EPSDT? 

What is the total budget? 

May we have copies of your budget? 

Documentation: Budgets. 

What are the total resources available for EPSDT including state appropriations 
local appropriations, volunteer time, overlaps with pre-existing children 
and youth programs? 

How much is budgeted for outreach? 

What are the costs of notification per client? 

How much of the EPSDT budget is for non-medical services? 

Are diagnosis and treatment costs charged to EPSDT or Medicaid? 

What are the other budgetary sources for EPSDT funds? 

How much is a single screening cost, including outreach, screening, and case 
management? 

What are the costs of treatment by disease category? 
What data are available on cost effectiveness? 

May we have any documentation on cost effectiveness studies? 

How much do cost considerations impede implementation? 

What would full implementation of EPSDT cost? 

Documentation: Budget for Medicaid and EPSDT 

Gost agreements with other agencies 

Cost effectiveness procedures and studies 

Fee schedules 

Procedures for reimbursement. 



PROVIDER AGREEMENTS 

How many providers are available to you for EPSDT services? 
How many do you need for full implementation? 

Do you have any cooperative arrangements with the Medical Society, or any other 
medical service, may we have copies of these agreements? 

Is there any physician resistance to participation in EPSDT? 

What are the reasons for this? 

Documentation: Provider agreements with the EPSDT agencies 

Medical Society agreements with EPSDT agencies. 

CASE MANAGEMENT 

Who is responsible for monitoring the client through EPSDT? 
Is case management continuous or segmented? 

If more than one individual or an agency is responsible for case management 
what are the divisions of responsibility? 

May we have copies of any guidelines or inter-agency agreements pertaining to 
this? 

What agency is the repository for client records? 

Documentation: Case worker guidelines 

Inter-agency agreements 
Client forms. 



XIII , 



APPENDIX B 
STATE DATA FILE MATRIX 



KEY 

STATES 

FL = FLORIDA 

IL = ILLINOIS 

LA = LOUISIANA 

N.O. = NEW ORLEANS 

OK = OKLAHOMA 

SC = SOUTH CAROLINA 

WA = WASHINGTON 

TECHNICAL 

C = COMPUTER FILE 

DT = DISPLAY TERMINAL 

HC = HARDCOPY AND/OR MICROFILM 

SC = SINGLE CODE STORED ON COMPUTER FILE 

SV = ONLY SOME VARIABLES STORED ON COMPUTER FILE 

BC = BLUE CROSS/BLUE SHIELD 




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Li . 






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LU 


1 

+ 




C_J 




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8 — 






CO 


G— 


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o 








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o 














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if 


1 1 
1 1 




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A/ 

or. 


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rv 
LX. 






ZJ 








( — ! 


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LLJ 


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1 




o 




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1 








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LLJ 




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LU 


t— 1 


o_ 


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1 

r— 


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LL. 


CJ 


LL 








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ll_ 


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LL. 






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LU 




LU 


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1 1 1 


1 1 1 














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LLJ 




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CO 


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LLJ 


1. _ 


LJ 


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UJ 




iii 
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DC 


1 

1 






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LLJ 


t— 4 


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LLJ 


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u_ 


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iii 

LU 


CO 


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ll. 


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Q_ 




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o 


DC 


1 

1 








i— 


LX. 


Q 










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^™ 


LL_ 


1 i 1 


LL. 


LLJ 






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1 




LU 




LU 


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CJ 


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LU 


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LX. 


LU 


o 


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DC 


< 


1— 


LJ 


rv 

LL. 


LJ 


Li- 




LjL. 


Ll. 




i 

—J 


1 — 


1 1 




I 1 

UJ 


! — 


1— > 


1 ' ■ 1 


i — 


iii 

LU 


iii 
LU 


LJ 


CJ 


o 


O 


> 




1 1 
Ll— 


/ 


ll n 

LL. 


} 


LU 


o 


LL. 


>- 


<L 


<c 


3- 


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LL. 




CO 


Q 




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Ll 


o 


1— 


ll. 


Ll. 




a 




t — V 
(—3 




/— \ 
f—j 


LX. 






_1 


CJ 


DC 


LU 


DC 


LU 


LU 


1— 1 


LU 




h- 


UJ 


DC 


ZD 






X 




\J J 


1 1 1 




I l I 
LLJ 


J 


t . 

r— 


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1 


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LU 


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o 


CD 


CD 






DC 


O 


DC 


CJ 


PS 


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< 




Q 


Q_ 


a: 












D_ 


LU 








< 


< 


X 


1—4 


O 


o 


o 


o 


LU 


< 


o 


< 


LU 


LU 


a 












LU 


DC 




- 


- 


_l 




CD 


( H 
V— 


( — I 


rv 

L_L_ 


f — \ 
I — 1 


LL. 




■ 

■ 


i i 


Ll, 




CO 


CO 


rrH 


rsi 








CO 


h- 


— 1 






U_ 


LL. 


ZD 




tr- 


/-\ 
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Q- 


o 


LU 


Q 


































O 


_| 


ill 




LU 






rv 


1 1 1 


































DC 


LU 


> 


1 


> 






Q_ 




< 




o 


Q 












LLl 


u_ 








CD 


DZ 


X 


















































1- 


















































< 








i 




> 




•— < 






































i — i 




i — i 




1—0 


> 


> 


































* 



XV, 



APPENDIX C 
STATE EPSDT COMPONENT MATRIX 



KEY 

STATES 

FL = FLORIDA 

IL = ILLINOIS 

LA = LOUISIANA 

N.O, = NEW ORLEANS 

OK = OKLAHOMA 

SC = SOUTH CAROLINA 

WA = WASHINGTON 

COMPONENTS 

BC = BLUE CROSS/BLUE SHIELD 
CP = CERTAIN PROCEDURES 
DR = IF DIRECTLY REFERRED 
M = MEDICAID 

PHU = PUBLIC HEALTH UNITS 

R = REVIEW ONLY 

WL = WHICHEVER IS LESS 

FA = FISCAL AGENT 

NC = NO CHARGE TO TITLE XIX 



o 

CO 



o 



X 

I— I 

I— 



CO 
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I— 

<c 

h- —I 

col u_ 



CD 
Q_ 

o 

C_J> 



CO 
Q_ 



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r— 

(— 

CO 





CO 






CO 


CO 


CO 






CO 




CO 


CO 


CO 


CO 




CO 


CO 


CO 






CO 


CO 


CO 




LU 


o 




LU 


LU 


LU 


O 





LU 




LU 


LU 


LU 


LU 




LU 


LU 


LU 


O 




LU 


LU 


LU 




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2: 




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2: 


2: 


>- 




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2! 




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>- 




CO 








CO 


CO 


CO 




CO 




CO 












CO 








CO 




CO 




LU 


o 




O 


LU 


LU 


UJ 





UJ 




LU 


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LU 


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LU 




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CO 


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CO 




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CO 




CO 




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LU 


LU 


LU 





LU 







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LU 


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2: 




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2: 


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u_ 


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LU 


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| | 


I | 




























CO 




CO 


CO 


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CO 


CO 










CO 








CO 


CO 






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LU 




LLl 


LU 


LU 




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UJ 




LU 


LU 


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LU 


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LU 


LU 






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LU 










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2; 


✓ 
















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CO 


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CO 




CO 


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CO 






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tr\ 
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O 


LU 


LU 


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LU 


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LU 


LU 


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LU 




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1— 1 




2: 


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2: 


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co 
















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ry 








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1 
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t~\ 
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1 




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X 


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1- 


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CD 


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LL. 


0_ 


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LU 


LL. 


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< 






1 — 1 


< 


_J 






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X 


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CC 




CO 


Q 


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Q 


D_ 







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1 — 1 




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O 


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CO 


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PQ 


CQ 





LU 


LU 


or. 


CO 




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Q 


2: 


a 


2: 


cc: 


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PQ 




PQ 




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PQ 


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5" 




XV 


(/1 

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CO 






r-~> 
t — 1 




1 1 1 


1 1 1 

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LU 


CJ 




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ry 


r— \ 


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1 


ry 

LL. 


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CO 


m 


CD 





ZD 


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zr 


Q 


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s: 






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Q 


Q 


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CO 


a. 


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h- 






1 — 1 














a: 










2: 










2: 














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1- 


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LU 


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Q 


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1— 1 














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XVI 1 1 



APPENDIX D 
STATE FORMS ON FILE 




STATE FORMS 



FLORIDA 

- SAMPLE HEALTH CLINIC SCREENING APPOINTMENT NOTIFICATION 

- INFORMED CONSENT FORM 

- SAMPLE EXPLANATION OF TREATMENT PERFORMED OTHER THAN PROCEDURE 
CODES (OPTIONAL AND NOT UNIFORM) 

- REQUEST FOR PAYMENT (BILLING FORM FOR EVERYTHING) 

- MONTHLY MEDICAID SCREENING REPORT (FILLED IN BY CLINIC) 
" STATE TOTAL OF MONTHLY REPORT 



ILLINOIS 

™ REDETERMINATION OF ELIGIBILITY (FILLED IN BY CASEWORKER) 

- MEDICHEK APPLICATION FORM (SCREENING) 

- MEDICHEK SCREENING SUMMARY (BILLING AND HISTORY FORM) 

- DENTAL SCREENING SUMMARY (BILLING AND HISTORY FORM) 

- VISION/HEARING SUMMARY (BILLING AND HISTORY FORM) 

- STATEMENT OF OPTICAL GOODS AND SERVICES 

- DENTIST STATEMENT 



LOUISIANA 

- SOCIAL SERVICE CERTIFICATION AND DISPOSITION 

- SERVICES RENDERED TO CHILDREN ELIGIBLE FOR EPSDT (SCREENING FORM) 

- SOCIAL SERVICE CASE FORM 



NEW ORLEANS 

- CLINIC ENCOUNTER FORM 

- PATIENT REGISTRATION FORM 



OKLAHOMA 

- SOCIAL SERVICES FORMS K"l TO K~16 ?, 17. (WE HAVE COPIES OF 

K-l-10-11-15-12-5-6-1^-2-3-13- 16.) 

- CASE INFORMATION FORMS A & B 

- SOCIAL SERVICE FORM 3 & 4 (OPENING A CASE) 

- ADM- 3 6- K physician's report and claim for periodic screening 

AND RELATED PROCEDURES 



SOUTH CAROLINA 



- SIX-PART FORM FOR SCREENING AND DIAGNOSIS, PLAN OF TREATMENT 
AND TREATMENT COMPLETED 

- CLIENT INFORMATION SUMMARY 

- BLUE CROSS/BLUE SHIELD TREATMENT FORM 



WASHINGTON 

- EARLY SCREENING AND DIAGNOSIS BILLING FORM 

- PHYSICIAN'S INVOICE 

- HOSPITAL INVOICE 

- MEDICAL VENDOR INVOICE 

- RECOMMENDED REFERRAL FORM 



t 



CMS LIBRARY 




3 flOIS D00LH531